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St. Luke’s Physician Group Closes HCC Coding Gaps with PINC AI™ Technology


Key takeaways:

  • St. Luke’s Physician Group is on a mission to improve its hierarchical condition category (HCC) coding and clinical documentation in order to ensure appropriate Medicare reimbursement and provide high-quality care to patients.
  • The physician group utilized an advanced HCC analytics platform, the PINC AI™ CQDoc Insights, to identify HCC improvement opportunities.
  • With CQDoc Insights, St. Luke’s Physician Group can better manage the health of its patient populations and improve clinical documentation, leading to more accurate HCC coding.

From volume to value. Clinicians are operating in a whole new world as healthcare transitions to value-based care (VBC). In contrast to the conventional fee-for-service model, VBC places more of an emphasis on quality than quantity. In a world of VBC, the need for quality reporting by providers is rising in importance. Accurate documentation and hierarchical condition category (HCC) coding is necessary to report treatment for complex conditions.

HCC Coding Basics

Patients with chronic illnesses play a significant role in the continual rise in healthcare costs, and HCC coding is a method of accounting for the extra care and resulting expense that these complex patients require. The HCC diagnosis coding methodology was created by the Centers for Medicare & Medicaid Services (CMS) as a risk assessment tool that gives a severity value to certain chronic conditions that contribute to overall healthcare costs.

HCC coding is used to determine a patient specific risk-adjustment factor (RAF), which predicts the cost of patient care for a healthcare organization. The more comorbidities that are being treated, documented, and reported with the specific HCC diagnosis codes, the higher the RAF score. A high RAF score notifies Medicare and commercial payers that the patient's projected cost of care would exceed the benchmark for the primary condition. When HCC codes are accurately documented, a more precise projection of the patient's anticipated overall cost of care and associated Medicare reimbursement is provided.

Improving HCC Coding Accuracy for Value-Based Care

Accurate HCC coding and documentation is pivotal to VBC. The question remains, which healthcare organizations will set the example and how quickly can others catch up? St. Luke’s Physician Group is one such organization that is setting the pace by making significant changes to better align with the value agenda. St. Luke’s Physician Group is a non-profit, regional, fully integrated, nationally recognized network providing services at 14 campuses and more than 300 sites in eastern Pennsylvania and western New Jersey.

While St. Luke’s Physician Group prides itself on providing safe and quality care; they understand there is always room for improvement. One such area was their HCC coding and documentation initiatives. St. Luke’s Physician Group sought to improve documentation of its care for patients with chronic conditions to assure appropriate reimbursement that could be reinvested in patient care and infrastructure. St. Luke’s Physician Group turned to the Premier’s HCC Advisory Services team and their advanced HCC analytics platform, CQDoc Insights, to identify HCC improvement opportunities. The PINC AI™ assessment yielded three key findings for St. Luke’s Physician Group’s leadership team to consider in improving their HCC coding.

Finding One: Engage in Staff Education and Awareness

Clinicians undoubtedly play a crucial part in documenting patients' conditions with HCC codes, but they shouldn't be left to handle the difficult aspects of coding on their own. As of 2020, there are 86 HCC codes, arranged into 19 categories. These 86 codes are comprised of 9,700 ICD-10-CM codes, each representing a singular medical condition. The complexity of the HCC system lies within the granularity of the diagnosis codes that roll up into the HCC codes. Expecting providers to be knowledgeable about every diagnosis code when they already have so much on their plate is impractical.

“One of the things that we first struggled with while working with our specialists was explaining all of the HCC codes to them which was overwhelming,” said Linda Gately, Vice President of Quality Performance Improvement and Compliance at St. Luke’s Physician Group. “Finally, we gave each specialty instructions to identify the 10 HCC categories in which they are most involved with, understand the HCCs related to each of those 10, and document as such.”

One of the biggest educational points to drive home to clinicians is not what score they should look for, but the importance of accuracy. St. Luke’s Physician Group provided its staff training and support, which helped everyone appreciate the value of accurate clinical documentation and its bearing on reimbursement and Medicare billing compliance.

Finding Two: Create an Accurate Problem List

The electronic medical record (EMR) problem list plays a significant role in healthcare. It offers a way to document factors that have an impact on patient health, such as illnesses or injuries. A typical problem list will specify the time of the incident or condition as well as the clinician’s strategy for treating it. As a result, problem lists serve as a vital means of communication in the healthcare industry during the course of patient treatment.

However, more often than not, a patient's problem list can fill up with out-of-date and frequently inaccurate information. Regular maintenance is required to obtain better patient care if the problem list's objective is to convey an accurate read on the issues the patient is experiencing. With the help of PINC AI™ CQDoc Insights, St. Luke’s Physician Group was able to review documentation and update its problem list

“One of the features we noticed in CQDoc was the ability for us to do a global clean-up of our problem list rather than a patient-by-patient basis. Providers tend to choose what's on the problem list,” said Gately. “So, if the problem list has diagnosis that is no longer valid, but the old diagnosis still remains providers just tend to look at what's on the problem list and choose those diagnosis. Instead, they should clean up that problem list and move those old diagnosis to past medical history.”

St. Luke’s Physician Group conducted provider education on the value of accurate problem list documentation. Clinicians were then able to understand how accurate problem lists not only enhance coding and reimbursement but also guarantee that the next provider has the most accurate clinical picture of the patient.

Finding Three: Monitor Performance Using Data and Analytics

Tracking performance is imperative for identifying future opportunities for HCC coding and documentation accuracy improvement. Measuring outcomes offers stakeholders compelling data that demonstrates advancements made, such as an improvement in key problem list diagnoses or a decline in the number of patients who did not receive an annual wellness visit.

Using the PINC AI™ CQDoc Insights data and analytics capabilities, St. Luke’s Physician Group was able to track progress and provide specific feedback to providers and other healthcare leaders. Subsequently, PINC AI™ CQDoc Insights helps to make sure that diagnoses are not left unaddressed. “We tried to use some other products to assist us with our HCC coding, but CQDoc was really the first tool we looked at that would allow us to quantify and be able to share actionable information with our providers,” said Gately. “Other HCC products rely more on re-validation than identification of new HCC opportunities. Information is powerful and CQDoc provides us with meaningful and useful insights we can share with multiple audiences, including providers, administrators, and coding managers. When we give our providers a report, they can see how they compare to each other and then eventually how they compare to national averages.” The PINC AI™ CQDoc Insights tool is designed to help healthcare organizations improve HCC coding and more accurately reflect patient complexity. For example, the PINC AI™ CQDoc Insights tool can analyze outcomes to determine providers with recurring errors as well as audit sample of encounters to determine if documentation:

  • Supports the codes assignment.
  • Affects patient care treatment.
  • Impacts management of the patients’ care.

With these insights, St. Luke’s Physician Group has a better picture of their patient population and what their needs are.

The Road Ahead with the PINC AI™ CQDoc Insights

St. Luke’s Physician Group VBC journey is far from over. The physician group intends to keep up its improvement efforts to guarantee accurate documentation of HCC codes. Aided by the PINC AI™ CQDoc Insights tool, St. Luke’s Physician Group is confident that they will be able to achieve their goals. “This is one of the most collaborative processes that I've ever been part of. It's just really been a great team effort,” said Gately. “This was not a process that took months and months to implement. We were able to do this pretty quick. I would anticipate at least 10 to 20 times return on our investment.”

The infrastructure required for St. Luke’s Physician Group to successfully monitor and react to future changes in patient populations and HCC codes is now possible thanks to the PINC AI™ CQDoc Insights tool. Although it can be challenging for healthcare organizations to change how they document chronic illnesses, doing so enables them to gather more detailed diagnoses, leading to better care for complex patients and appropriate reimbursement.

What are you doing about HCC coding? Learn about what a partnership with Premier’s Population Health team can do for your healthcare organization.

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