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From Recapture to Revalidation: PINC AI™ Stanson’s Trailblazing Approach to HCC Coding

Key takeaways:

  • PINC AI™ Stanson is spearheading a groundbreaking move in HCC coding – shifting from traditional recapture methods to real-time revalidation.
  • PINC AI™ Stanson’s CodingGuide solution not only improves HCC coding accuracy but also streamlines documentation processes, allowing coding teams to focus efforts more efficiently.
  • By empowering healthcare providers to proactively manage chronic conditions, PINC AI™ Stanson’s CodingGuide contributes to improved outcomes and a patient-centric approach to healthcare.

The healthcare industry is ever evolving, and so are the methodologies around Hierarchical Condition Category (HCC) coding. HCC coding, introduced in the early 2000s, aims to assess the health risk of Medicare Advantage (MA) plan beneficiaries. The initial emphasis was on recapture – identifying and capturing chronic conditions that might have been overlooked in traditional fee-for-service coding systems. This approach focused on retrospectively capturing missed diagnoses to ensure accurate risk adjustment (RA) and appropriate reimbursement.

Recapture, however, presented a set of challenges. It relied heavily on historical claims data and retrospective reviews, often leading to delayed identification of relevant conditions. This lag in data processing hindered the timely adjustment of risk scores, impacting both providers and payers.

Introducing PINC AI™ Stanson’s CodingGuide

Enter PINC AI™ Stanson's CodingGuide—a revolutionary solution shifting from traditional recapture to revalidation and suspecting HCC clinical decision support (CDS). Revalidation places emphasis on validating and updating existing diagnoses in real-time, fostering a more accurate approach to HCC coding.

PINC AI™ Stanson's CodingGuide leverages AI-enabled CDS to simplify complex HCC coding. This cloud-based solution recognizes that clinical conditions evolve, patients change and diseases progress. It introduces a cutting-edge revalidation tool that meticulously examines electronic health records (EHR) and clinical notes, ensuring that HCC codes accurately reflect the current state of a patient's health.

The Right Code, Not the Last Code

While conventional solutions often rely on the last code assigned during a visit, PINC AI™ Stanson’s CodingGuide with revalidation evaluates the latest clinical information. This allows providers to stay informed about patients’ evolving health conditions.

“We all know that patients are complex, and their clinical conditions change frequently. So, I think through the revalidation process, it really works to reduce the noise and present the codes that are most pertinent at the time, representing the patient's condition,” said Dr. Patrick McGill the Chief Transformation Officer at Community Health Network.

For example, if a patient had diabetes without complications last year, traditional HCC coding solutions would likely suggest the same code for the current year. However, PINC AI™ Stanson’s CodingGuide recommends adjusting the code to 'diabetes with chronic kidney disease (CKD),' transitioning from HCC 19 to HCC 18 after verification of chart elements. This refined code not only ensures greater accuracy but also carries financial significance and aligns impeccably with coding compliance standards.

The move towards revalidation has improved RA models by providing more accurate and up-to-date information on patient health status. This ensures that risk scores accurately reflect the current health condition, facilitating fair and timely reimbursement.

Beyond financial implications, revalidation promotes better patient care. The real-time validation of diagnoses allows healthcare providers to manage and treat chronic conditions, leading to improved health outcomes for patients.

Furthermore, PINC AI™ Stanson's CodingGuide stays ahead of the curve by including expanded categories to cover the HCC V28 transition over the next two years. This phased approach ensures seamless integration with evolving coding standards, demonstrating the product's commitment to staying current and relevant.

“Community Health Network has really observed tremendous improvements since implementing CodingGuide. We've seen higher follow rates, which results in less fatigue for clinicians. We've seen improved accuracy, which leads to better coding outcomes and coding results,” said McGill.

A New Chapter in HCC Coding

The evolution from recapture to revalidation in HCC coding reflects PINC AI™ Stanson’s dedication to accuracy, efficiency and improved patient outcomes. Prioritizing revalidation over recapture not only addresses current coding needs but also anticipates future shifts in healthcare dynamics, promising a new era of precision and accuracy in HCC coding. Embracing this change ensures that HCC coding remains an invaluable tool for navigating the intricacies of RA in modern healthcare.

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