A Provider’s Glimpse Into A Plan’s Revenue Capture

By Holly J. Cassano, CPC

CEO – ACCUCODE Consulting, LLC


Twitter: @hollycassano




•  HCC  Coding and Capture Process – Provider and Plan

•  AWV –The Importance of Annual Wellness Visits

•  Prospective /Retrospective  HCC  Capture



 HCC Methodology:

HCC payment rationale was developed  to mirror the individual Health  Risk Profile (HRP) of Medicare Advantage members  and utilizes ICD-9 information as the primary indicator  to determine  a  member’s health status.

•  There are thousands of ICD-9 codes – that map to less than 100 Hierarchal Condition Categories (HCC’s)

•  The HCC’s and CDC’s are what ultimately drive the PMPM (per member per month) Premiums paid to a Medicare Advantage plan.

HCC Coding Process:

•  Providers:  Assessments/Plans/DX Codes Documented In Charts

•  Providers: AWV – Annual Wellness Visits

•  Providers/Plans: Coding Precision & Specificity 

•  Providers/Plans – Up To 8 DX Codes Submitted To Plan – Provider Ability To Submit Max DX Codes – Use Of 99080* If Necessary.

•  Plan Sends To Raps/DX Codes Converted To HCC Codes

•  CMS Factors Plans Risk Adjustment

•  Allows Plan & Providers To Deliver Better Benefits/Care

Preparing for the AWV

►  In advance of the AWV – Health Risk Assessment (HRA) must be completed and can be done in any of the following ways:

•  The form can be mailed to the member in advance

•  The office staff can call the member and complete the form together

•  The member can complete the form in the office before the visit, either on paper or using a computer kiosk

•  The physician should review any available health plan reports to ensure that they are aware of any HEDIS/5Star needs or other conditions that should be addressed at the visit

•    (The physician may wish to pre-order labs/x-rays/EKGs in advance of the visit, based on these reports.)

•  A Certified Coder should review the physician’s documentation after the visit, to ensure that all current HCC’s are documented and that the physician documented the review of the HRA in conjunction with the AWV.

•  The HRA has been required since 1/1/12. 

The Two- Pronged Approach To HCC Capture

When choosing a  vendor to  assist with Prospective and Retrospective HCC Capture – it is important to have a checklist that will  clearly define the Plans expectations from that Vendor in order to  allow for a successful partnership.

If  a Plan solely focuses on disease management to decrease costs – hence  neglecting to  develop an effective HCC strategy,  the Plan runs the risk of under-reported HCC codes.  Although the Plan may still save potentially $150-$250 per member, they still be deficient on the coding side if they do not factor HCC ‘s into their business models and work with vendors on aggressive Prospective and Retrospective HCC Capture.

Vendor Checklist: Putting the Pieces in Place

Proper HCC classification depends on both a Plan’s ability to obtain accurate diagnostic HCC information and a Plan’s ability to report that information accurately to CMS.  This is where a Vendor’s ability to conduct a majority of the Retrospective coding initiatives , or first prong of the journey successfully becomes imperative  – so that the Plan can  focus on the second prong  -  Prospective coding initiatives.

Chart Extractions:

•  Established relationships in physician network

•  # Number of clients – can they handle Plans  volume – on time to scan appointments/minimize rescheduling

•  Ability to generate pursuits/set scan appointments

•  What the extractions should/should not include (HEDIS measures/SNP forms/Progress Notes etc..)

•  Flexible chart retrieval services based on the specific needs of the Plan

•  # Scan techs on staff -  geographic ranges and # of  staff  to support a provider network area

•  Security/HIPAA compliance -  Equipment types etc…Flash Drives/Portable Scanners/do they bring paper etc. if records have to be printed so as not to use provider’s resources

•  Diverse staff to meet different market needs – Excellent Provider/Plan relationship skills

Reporting Capabilities:

•  View electronic images of all medical records 

•  # AAPC/AHIMA Certified Coder’s on staff (in-house and remote)

•  Generate accurate coding reports based on scans/minimize duplications/errors

•  Code each record using an online code reporting/capture for DX/HCC codes

•  Accurately identify areas in the record that support the HCC findings

•  Identify provider deficiencies in documentation and coding

•  Annotate the electronically coded record with notes with report generation to assist Plan in targeting deficient providers

•  YTD/MTD real-time(with-in past 30 dys) updated report generation to identify low RAF score providers/providers whose HCC reporting is low in comparison to panel size

  HEDIS reporting abilities to assist providers/Plan obtain 4&5 Star ratings

•  Pharmacy/Utilization-Facility tracking/

•  Identifying members who have not been seen who are new to provider panel/or in the past six months

•  TAT from time of scan to coding with report generation to Plan

•  Monthly reporting with Plan to identify errors and generate corrective actions

Final Thoughts

Plans that focus in both areas and implement a Two-Pronged Approach and work with vendors both Prospectively and Retrospectively,  will see increased revenue  and  cost containment  through better disease management  by including a defined HCC  coding initiative – in fact a Plan that combines  both approaches can potentially increase revenue anywhere from $1500-$2500 per member with this methodology.

When a Plan has a targeted approach to HCC capture, Plans will be better at identifying high risk members and channel them into an appropriate disease management program.


“Success is simple. Do what’s right, the right way, at the right time.”

-          Arnold H. Glasgow

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