Best Practises for the Review and Audit of HCC Code

Best Practises for the Review and Audit of HCC Code

Best Practises for the Review and Audit of HCC Code

This year has brought forth a fresh set of difficulties for health managers. The previously gathered CMS HCC code may have missed the opportunities and must now be recollected. So, how do the top health managers position the teams for success?

On the other hand, the majority of high-performing organizations already have proper clinical processes in place and are prepared to move on to the next stage of execution and analysis for a more precise RAF score and effective CMS HCC code collection. The group’s priorities for the coding review have been defined here.

Recognize HCC Coding Requirements

Understanding the HCC code rules is crucial before a risk coding study or audit. The diagnoses covered in each HCC category are listed in the Centres for Medicare and Medicaid Services (CMS) specific rules for HCC coding.

To accurately assess the risk associated with the coding, it is crucial to comprehend the HCC categories, the codes used to assign them, and the documentation requirements for each HCC category. The danger of coding mistakes and potential audit results can be decreased with a thorough grasp of the HCC coding rules.

Create a thorough audit plan.

A thorough risk coding audit strategy is necessary to guarantee that all facets of HCC coding are addressed throughout the audit process. Examining medical records, provider documentation, and
coding procedures should be part of the audit strategy, emphasizing possible risk areas for coding mistakes.

To identify and correct any knowledge gaps that may raise the risk of coding mistakes, the audit plan should also include a review of the provider’s policies and practices for HCC coding and staff training and education on the subject. Potential audit findings and the general accuracy and completeness of HCC coding can be minimized by adding risk coding analysis into the audit process.

Carry out a Complete Code Review

It is crucial to evaluate possible areas of risk linked with coding mistakes throughout the risk coding review process,
in addition to checking all diagnosis codes issued to the patient for correctness and support in the medical record. As incorrectly allocated HCC code categories might result in underpayment and potential audit findings,
it is crucial to ensure that the HCC categories given to the patient are suitable based on the diagnostic codes and medical record documents. By incorporating risk coding analysis,
HCC coding may be more accurate and thorough overall while also helping to detect any possible danger areas.

Examine the provider’s documentation.

To ensure correct CMS HCC categorization, provider documentation is essential. It is crucial to check provider records during the audit process to ensure they reflect the diagnostic codes and HCC categories given to the patient. To enable proper HCC coding to be allocated, providers should be urged to record all pertinent diagnoses and conditions.

Tracking coding trends

The ability to spot possible risk areas due to coding errors and to indicate locations where coding procedures may need to be changed,
can be gained through tracking risk coding patterns over time. Healthcare organizations can spot possible coding mistakes and inconsistencies by
examining coding patterns and areas where staff training and education may be required to lower the chance of coding errors.

Risk coding analysis can be used to track coding trends to detect possible risk areas, reduce audit results, and enhance overall coding correctness and completeness.

Conduct staff education and training.

For proper CMS HCC, staff education and training are crucial. The HCC coding standards and recommended practices should be taught to all staff engaged in the coding and billing process. To guarantee that staff employees are informed of any changes to HCC coding requirements, offering continuing education and training is crucial.

Put quality assurance procedures into practice.

Putting in place risk coding quality assurance systems can assist in locating possible risk areas related to coding mistakes and
guarantee that coding standards are followed consistently throughout the organization. Periodic audits emphasizing potential risk areas, continuing checks of coding procedures for correctness and completeness,
and employee input on areas that want improvement are all examples of quality assurance systems.

Risk coding analysis may be included in quality assurance procedures to help identify possible risk areas,
likely lower the probability of coding mistakes, and increase overall coding correctness and completeness.


Accurate coding is critical for patients and healthcare organizations,
and HCC coding is a crucial component of healthcare coding and billing. Insightful CMS HCC reviews and audits can highlight areas where coding
procedures should be strengthened and guarantee that the proper HCC coding is allocated. Healthcare organizations may increase the accuracy of their HCC coding procedures and
make sure they are paid fairly for their services by adhering to these best practices.

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