St. Luke's University Health Network (SLUHN) teamed up with Premier's HCC Advisory Services team for guidance on how to improve HCC coding accuracy.
Using the PINC AI™ advanced HCC analytics tool, CQDoc Insights, SLUHN implemented new coding processes to close care gaps and improve care delivery.
Through a partnership approach, industry-leading consulting expertise, and actionable AI that works to solve healthcare’s pressing challenges, SLUHN’s shared savings or Accountable Care Organization (ACO) contracts and Risk Adjustment Factor (RAF) scores have all increased and, in some cases, the health system risk score outcomes are showing it’s a top performer in their region with payers.
When it comes to quality improvement, leading health systems often ask: "Where do we stand?" and "Can we get better?" These questions are some that staff at St. Luke's University Health Network (SLUHN) focus on as they work to improve their hierarchical condition category (HCC) coding and clinical documentation.
HCC coding, created by the Centers for Medicare & Medicaid Services (CMS), estimates a patient's future healthcare costs using the Risk Adjustment Factor (RAF) to adjust payments for Medicare Advantage (MA) plan patients. In essence, HCC coding provides a comprehensive view of the patient which is essential for measuring the quality and cost of patient care. Therefore, HCC codes must be accurately documented to help ensure healthcare organizations receive appropriate reimbursement and provide better care to their patients.
Many healthcare organizations are leveraging artificial intelligence (AI) to improve accuracy in coding. AI assists in analyzing patient data, identifying potential risk factors and suggesting appropriate codes, thus streamlining the coding workflow. This increased efficiency translates to higher-quality care and reduced costs, as providers can allocate more time to patient interaction and strategic decision making.
A Need for HCC Coding Improvement
Since April 2022, SLUHN, a nationally recognized nonprofit healthcare network, has partnered with Premier's HCC Advisory Services team for guidance on how to improve HCC coding accuracy. “Our goal is for every caregiver to excel in their work every day, and we’re constantly exploring new and innovative methods to support them in achieving that goal,” said Linda Gately, Vice President of Quality Performance Improvement and Compliance at SLUHN. The health system turned to PINC AI™, Premier’s technology and services platform, to enhance their current infrastructure, and implement new coding processes to close care gaps and improve care delivery.
When SLUHN first began their HCC improvement initiative, their focus was on primary care physicians (PCPs). PCPs have traditionally been tasked with accurately capturing HCCs since they treat patients with chronic conditions that are used to calculate HCCs. However, while PCPs play a significant role in HCC capture, it’s important to recognize that it’s not an issue exclusive to primary care. Healthcare organizations need all clinicians involved in the process to ensure appropriate care and reimbursement for high-risk patients. With this in mind, SLUHN healthcare leaders recognized it was time to also engage their specialists in the HCC capture process.
Using the PINC AI™ advanced HCC analytics tool, CQDoc Insights, SLUHN was able to identify HCC improvement opportunities. For example, SLUHN was able to look through CQDoc Insights opportunity report and found they were missing critical HCCs for their nephrology practice in some instances. Specific documentation needs exist for every medical specialty. Nephrologists, like other specialists, must balance documentation requirements, time constraints and patient compliance issues when treating patients with severe medical conditions. While specialty care presents unique challenges, the core tenets of engaging clinicians in HCC capture are broadly applicable.
SLUHN utilized three key strategies to engage their specialists in accurate HCC capture:
Define the role specialists play in HCC capture. Providing specialists with clear lists of HCC codes they are responsible for is a simple way to improve HCC coding. It isn’t realistic to expect a specialist to know all HCC codes. They should only be in charge of codes specific to their area of expertise as well as general conditions that any physician can identify. SLUHN has implemented this strategy by holding their specialists accountable for 10 core categories. “Asking our specialists to choose 10 HCC categories that relate to their specialty was a game changer,” said Gately. “They didn’t want to get best practice advisories (BPAs) on all 88 HCC categories and specialties should record the complex chronic conditions specific to their patients.”
Provide staff with HCC education. SLUHN discovered that it's critical to educate specialists not only on the value of HCCs for reflective reimbursement but to also help them adopt a more population-focused approach to care. Specialists often focus solely on their specific areas of expertise. However, educating them on HCC capture can provide a better understanding of the costs and challenges of managing serious illnesses, leading to increased collaboration with PCPs to manage these conditions more effectively. SLUHN conducts monthly HCC education meetings for primary care and specialty physicians. “When we look at CQDoc, we can pick out those providers who aren’t up to speed or aren’t doing as well as their peers and we have been able to provide targeted education to them,” said Gately. SLUHN also engaged physician champions across specialties who can help facilitate the implementation of the new HCC improvement initiative. Having a respected clinician in this role can go a long way towards ensuring cooperation, since providers tend to relate best to their peers.
Provide staff with coding support. Leading healthcare organizations invest in real time, technology-based coding support to boost performance. By performing coding quality audits with CQDoc Insights, SLUHN can simplify their revenue cycle processes, decrease claim denials and stay compliant with local and national healthcare laws. “CQDoc helped our coding team perform audits to review charts for our providers,” said Gatley. “We want to improve our performance, but we also want to make sure that we are in compliance and that anything that we bill is properly documented. This has improved the effectiveness and efficiency of our HCC team resulting in accelerated improvements in HCC coding outcomes.”
By following the three steps outlined above and utilizing performance data analytics provided by CQDoc Insights, SLUHN has enhanced their ability to measure, monitor and initiate actionable improvement. As a result, in all of SLUHNs shared savings or Accountable Care Organization (ACO) contracts, their RAF scores have increased and, in some cases, the health system is showing it’s a top performer in their region with payers. Furthermore, significant improvement was made across the nephrology specialists because of the focused analytics performance improvement initiative. “We provided information on coding that came from CQDoc to the Chair of Nephrology, which he shared in a meeting with all of his providers, and we saw a rapid increase in the performance of that group,” said Gately.
SLUHN is continuing to expand its HCC improvement initiative to more specialties throughout their facilities. As the initiative progresses, history indicates that reimbursement and regulations will only continue to evolve. In fact, CMS recently finalized the 2024 Medicare Advantage (MA) capitation rates and payment policies which will affect how Medicare plans are reimbursed and how they report and manage risk adjustment operations.
Despite these upcoming changes, SLUHN is confident PINC AI™ will help them tackle this obstacle effectively and efficiently. “I don’t know what’s going to happen next year with CMS, but I do know we will be okay, and we will continue to do well because that’s our culture and we have good partners like Premier that we’re working with,” said Gately. “When we implemented CQDoc last year we anticipate at least 10 to 20 times return on our investment, which we have easily exceeded that estimate.”
Ultimately, improving HCC coding skills takes time and consistent effort. Maintaining a continuous focus on accuracy and quality is critical in optimizing appropriate reimbursement and reducing the risk of penalties. CQDoc Insights, with its AI-enabled capabilities, empowers healthcare organizations tap into their current patient data to make the complex HCC coding process simpler. “I do think it’s all about relationships. It's about relationships with our providers. It's about relationships with our payers. It’s about our relationship with you (Premier). It all helps us to be more successful and it really is the key,” said Gately.
Premier’s HCC Advisory Services combine their industry-leading expertise with advanced AI technology, empowering clinicians and coders to optimize their approach. By harnessing the power of AI, unnecessary tasks are minimized enabling clinicians to focus on critical aspects of patient care. This synergy leads to improved outcomes and streamlined workflows, ultimately driving better results and better healthcare delivery.
The insights you need to stay ahead in healthcare: Subscribe to Premier’s Power Rankings newsletter and get our experts’ original content delivered to your inbox once a month.
John Pitsikoulis, RHIA
Principal, Population Health Management & Performance Improvement Advisory Consulting Practice
John brings over 35 years of progressive revenue enhancement, prospective payment system reimbursement, coding, and documentation compliance expertise. John has led numerous multi-system high profile engagements, including prospective payment system revenue integrity, operational process improvement, healthcare emerging technology, litigation and compliance engagements.