Risk Adjustment
CMS-HCC Auditing
Hierarchical Condition Category (HCC) coding is a risk-adjustment model originally designed to estimate future health care costs for patients. HCC coding helps communicate patient complexity and paint a picture of the whole patient. In addition to helping predict health care resource utilization, RAF scores are used to risk adjust quality and cost metrics. By accounting for differences in patient complexity, quality and cost performance can be more appropriately measured.
CMS uses two models: The first, CMS-HCC is the model used to pay Medicare Advantage Organizations. The second model was developed after the passage of the Affordable Care Act to pay health insurers in the ACA marketplace. ReviewMate currently has a CMS-HCC module and an HHS-HCC module under construction.
ReviewMate pushes important metrics like performance targets and averages to keep you proactive on audits. ReviewMate has multiple options for controlling HCC audits.
In addition to ReviewMate's standard features for auditing, our HCC auditing module features:
- Overridden HCCs due to the hierarchy structure are identified on the screen so the auditor can readily see which diagnosis codes will be considered into the patient's score.
- Original, revised and net HCC weight for each calendar year.
- Each calendar year for each patient has an “Analyzer” button where the auditor can view what diagnoses and HCCs are missing for a particular calendar year.
- Discover missing encounters in order to capture necessary HCCs.
- Conduct muti-year HCC audit in one review.
All auditing account types are considered part of the core of ReviewMate's auditing system that covers many features such as:
- Customizable settings for analyzing overall accuracy rates. Adjust for particular coders, tasks or firms.
- Built-in code look-up for performing research intuitively.
- Conversations between the auditor and coder are saved in a chronological manner and can be accessed by any user.
- Customizable dashboards to enhance the user experience.
- Identification on the screen of codes with CMS-HCC values.
- Grouping and pricing take place within the software eliminating the need for auditor to "toggle" between an encoder and ReviewMate for better resequencing decisions.
- Full suite of edits/warnings including gender and age conflicts, MCE edits, critical error and TruCode warnings.
- Accuracy rates available real-time and can be sliced and diced to accommodate different situations and date patterns.
- Multiple user levels allow view-only access to any interested parties providing transparency within your organization.
- Full suite of references including Coding Clinic, CPT Assistant, Coding Clinic for HCPCS, Clinotes, Principal Diagnosis Analysis, DRG Analysis, and AHA Coding Handbook
- Reconciliation of rebuttals occurs inside of ReviewMate.
- Extensive library of customizable and exportable reports from raw data to Executive Summaries.
- "Audit the Auditor" available for a higher-level quality check of any audit in ReviewMate.