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Margin Improvement Case Study: Atrium Health Automates HCC Coding to Extend Labor and Ensure Accurate Reimbursement


The healthcare industry is constantly evolving and progressing at an unprecedented rate. For a health system to be effective, it has become increasingly vital to plan for the future.

The COVID-19 pandemic is a stark reminder of the significance of planning. Health systems across the country are working to improve their financial health as they steadily recover from the losses incurred during the pandemic.

Atrium Health, an integrated, nonprofit health system serving the Carolinas and Georgia, is no stranger to the importance of managing costs. Even though the health system was performing well, leaders believed they could do better.

“We have some strengths and some areas of opportunity. In regard to performance, we are pretty strong on the quality front. We have some good capabilities around utilization but on the coding side of things, we really had a lot of opportunity there,” said Peter Hiltz, Vice President of Business Operations at Atrium Health.

Specifically, Atrium Health’s leaders believed they were not accurately capturing all Hierarchical Condition Category (HCC) codes as was necessary. The health system serves very sick people yet their risk adjustment score, or RAF score, didn’t accurately represent the patients they were treating.

“We're a tertiary or a quaternary center. We have a lot of very sick patients, but the risk scores didn’t reflect that, so we knew that we were under coding,” said Hiltz.

Accurate HCC Coding Unlocks Improved Reimbursement

The RAF score is a predictive model that estimates the cost of patient care for a healthcare organization. A patient’s HCC codes, which indicate specific medical conditions, are an important component of the RAF score.

The HCCs, together with the patient’s demographic, determine the patient’s RAF score. Health systems that treat sicker patients require more and more expensive care, time and effort in the care delivery process. As a result, the higher the risk score, the more funding is provided to cover the costs of their more intensive care.

The accuracy and completeness of HCC risk adjustment coding is required for health systems to ensure compensation accurately represents the health of their patient population.

Atrium Health turned to PINC AI’s HCC Advisory Services team for guidance to help with this matter.

“A lot of times, it does add value to bring in a third party to help understand and really assess from A to Z what some of the opportunities are. In this case, HCC coding was an issue we needed to address,” said Hiltz.

Using PINC AI’s advanced HCC analytics platform, CQDoc Insights, an in-depth assessment process and hands-on consulting expertise, HCC improvement opportunities were identified at Atrium Health.

Here’s a look at what the assessment found.

Making HCC Coding Simple for Doctors

There’s no doubt that physicians play an important role in HCC coding, but the task shouldn’t be entirely placed in their hands. Clinicians have a lot on their plates so expecting them to be well-versed in every single diagnostic code is impractical.

This is an issue that Atrium Health is attempting to tackle head on.

While physicians play a key role in HCC outcomes, a shift in focus must occur towards improving the various processes to support the physicians in the delivery of care, documenting that care and an infrastructure to support the coding and billing of these services.

“There were some key coding opportunities that we were just missing. We were lacking some continuous education to providers around how coding was changing,” said Hiltz.

Closing the Coding and Documentation Divide

Clinical documentation is an important bridge between healthcare coders and physicians. This is a concept that Atrium Health struggled with. For Atrium Health’s clinicians and Corporate Coding Department, it was a challenge to work collaboratively.

It’s important to get all staff on the same page to improve the patient experience and obtain high-quality care at a low cost. The key to achieving this goal is open communication between clinicians and coders.

Maintaining communication between both parties is often a challenge due to busy schedules. However, improved communication creates positive changes among team members.

Coders can focus on advising physicians rather than playing mind reader. This leads to more direct efforts to educate clinicians and provide feedback when it comes to coding.

Optimizing the Electronic Medical Record (EMR) to Collect HCCs

For Atrium Health, the goal isn’t to turn physicians into master coders; instead the system is working to implement an infrastructure to manage the HCC coding process and responsibilities.

To better manage the HCC coding process, Atrium Health realized it needed to improve performance across the physician EMR workflow. While intending to improve care quality and efficiency, the EMR has inadvertently burdened clinicians and is now considered a leading cause of clinician burnout across organizations.

The same can be true for the physicians at Atrium Health. Their EMR had not been adequately configured to leverage the EMR capabilities, which is increasing physician workload, impacting HCC accuracy and increasing physician frustration.

The development of a physician EMR playbook would help solve this problem and assist with simplifying the physician workflow. This is especially crucial for Atrium Health since they plan to transition from one EMR system to another.

Once the new EMR is reconfigured and optimized, a playbook will give insights on “physician approved” best practice workflow options leveraging the standard features, functions and capabilities available with their new EMR platform.

In addition, improving the supporting infrastructure will enable the physicians to focus on the delivery of care, and the documentation of this care, for properly reporting the true severity of their patient populations. This includes establishing an effective approach for improving the various operational workflows such as pre-visit reviews, the annual wellness visit (AWV) process, coding, documentation, problem list protocol, etc.

To improve efficiency and quality within their organizations, health systems should always strive to learn and grow. This is what Atrium Health does well.

“I would say the relationship we have with Premier is pretty foundational to how we operate in preparing Atrium Health for the value journey and performing in the scope of the work that we have today,” said Hiltz.

Atrium Health’s ability to build on past success, adapt to change and accept guidance is unmatched. This in turn will lead to stronger healthcare delivery and ultimately save lives.

Ready to get started with quality improvement? Learn about what a partnership with PINC AI’s Population Health team can do for your healthcare organization.

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