Using HCC Coding, Risk Stratification to Enhance Patient Outcomes

To effectively document the severity of patient conditions and use risk stratification, the Community Health Network (CHN) in Indiana has streamlined hierarchical condition category (HCC) coding to drive better patient outcomes in their system. 

CHN began the streamlining process of HCC coding a few years ago to move toward value-based care contracts, taking a systematic approach around HCC and risk acuity coding. When assessing how CHN was performing, the organization turned its focus to ensuring quality and appropriate documentation of chronic diseases and complex conditions.

“There are benefits around appropriate documentation to show the management of the complex conditions in the complex patients that we’re taking care of. Without HCC coding, there’s no way to tell the payers, insurers, how complex the patients really are in the breadth of conditions that you’re managing with a patient,” CHN Chief Analytics Officer Patrick McGill told HealthITAnalytics.

In addition to providing a higher quality of care for patients, HCC coding is also cost-effective. McGill identified the cost benefits of HCC coding within value-based care contracts.

“There’s a financial component when it comes to baseline yearly expenditures, targeted expenditures, and shared savings in many contracts. That’s one of the many factors of calculating the shared savings and value-based contracts. It’s imperative to make sure that you’re appropriately documenting the severity of those conditions is something you have to do on a yearly basis,” McGill said.

Through a partnership with Stanson Health, a Premier company, CHN expanded its coding system to function efficiently with its electronic medical records (EMR). With the system, clinicians are alerted regarding documented conditions in a patient’s EMR. Clinicians then use the system to indicate if the condition is still active or not. After the re-documentation process, CHN began examining suspect codes.

Complex and suspect codes are used in patient examination and risk stratification. McGill gave an example that a patient’s chart might indicate they have chronic kidney disease and diabetes. With a complex code, the physician could document a more specific and higher acuity code of diabetes with chronic kidney disease.

With the assistance of Stanson Health’s algorithms, CHN then began looking at suspect codes and catching data that the documentation process could have missed.

“Maybe a code hasn’t been documented, but there’s evidence of a condition in the chart through labs or other information. The chart would prompt the clinician to say, ‘Hey, this patient’s never been diagnosed or documented with diabetes, but they’ve got an elevated A1C. Does this patient actually have diabetes? And should you document those types of workflows in the EMR?’” McGill explained.

Additionally, McGill said that when using HCC coding to document the severity of conditions, coding can serve as an important component of risk stratification and determining the needs of patients.

“HCC coding is another component we can use for risk stratification to understand who are some of our sicker patients that maybe need additional focus or additional resources, care, coordination, care navigation, and maybe they would benefit from a pharmacist. We use HCC coding or risk acuity coding as one component to drive better outcomes and improvements for the patients,” McGill said.

To continue improving the quality of care for their patients, McGill said the CHN has moved to a panel-based management system for their primary care physicians.

“Risk acuity, coding, and HCC coding is another component that we use to show the severity of the patient panels for a clinician and a physician. Especially when it comes to taking care of a thousand low-risk patients is a lot different than taking care of a thousand very high-risk patients. HCC can be used when it comes to panel management as well,” McGill said.

According to McGill, the goal is to keep patients in focus by documenting the severity of conditions and identifying people who might benefit from additional resources.

McGill highlighted the benefits of having a partnership with Stanson Health in implementing the HCC coding technology. The partnership allowed for a collaborative effort and relieved some of the responsibilities from CHN. While HCC coding provides better care for patients, it could easily represent another responsibility for physicians.

“This is a way where we can use technology to assist and take some of that heavy lifting off the plate of the physicians. And it’s been very well received. Our ATC alerts, typically with any kind of clinical decision support, we hope for about a 40 percent follow rate and are doing well,” McGill continued.

“We see with these alerts, we have over a 60 percent follow rate, and we received very little pushback on these alerts. Through the follow rate and the feedback that we get, that the physicians and clinicians are really responsive to this workflow and see the benefits of it as well.”