Now that CMS has announced their plan for implementing Medicare Advantage rule changes over the next three years, it’s more important than ever to streamline the ways we retrieve and interpret medical records.
The CMS plan includes the removal of more than 2,000 diagnosis codes from the current risk adjustment model, requiring providers to get much more precise with their diagnoses or risk missing out on premiums.
Unfortunately, traditional systems for medical record retrieval, storage, and analysis are not sophisticated enough to adequately meet providers needs under these new rules.
Shortcomings of the current system Even with the implementation of EHRs, 78% of hospitals are still “often or sometimes” using mail and fax to receive medical records, according to a 2021 report from the Office of the National Coordinator for Health Information Technology.
And when (or if) those records arrive, they’re often incomplete, illegible or contain far too many pages for a provider to read and analyze before the clinical encounter.
Because of this, at-risk providers often go into a clinical encounter with limited-to-no understanding of the patient’s history. This makes it nearly impossible to do accurate and comprehensive HCC coding.
When a provider does identify diagnoses and related treatment plans, these are typically documented in a progress or SOAP note. In fact, up to 70% of clinical value is contained in these notes.
After the clinical encounter, an independent coder reviews the provider’s documentation. Unfortunately, because progress notes are unstructured, there’s no good way for these coders to extract the information they need from the note.
Accurate diagnosis matters more than ever When a provider incorrectly diagnoses a patient — or presents a diagnosis without a treatment plan — it puts them at risk of payment retraction or fines for any discrepancies found during a Risk Adjustment Data Validation audit.
On the other hand, when a provider misses a diagnosis, it lowers the patient’s RAF score and negatively impacts the payment the provider receives from CMS for that patient’s care.
These consequences were already a significant source of concern for at-risk provider groups. But now that the list of HCC codes is shrinking, it’s more important than ever to code accurately and to catch all diagnoses.
Accelerating the risk adjustment timeline As health systems are looking for ways to improve their HCC coding processes, a natural starting point is to enable providers to start the risk adjustment process before they ever meet with the patient.
