We’ve all heard the adage – when it comes to healthcare, if it wasn’t documented, it wasn’t done. This couldn’t be more true when it comes to value-based care – particularly as it relates to the Centers for Medicare & Medicaid Services risk adjustment program. This innovative program offers higher payments to providers who deliver care to patients who fall into certain high-risk groups – assuming that caring for these patients requires more time and resources than it takes to deliver care to healthier patients.
This concept is great in theory – it should allow providers to spend more time with the patients who truly need more support. For once, providers can be rewarded for doing the right thing. But, wait – everything that’s great in theory has some downstream challenges and this program is no exception. CMS has to have proof that providers are seeing patients who have qualifying conditions – and of course, they also have to verify that they are being cared for thoroughly and in line with evidence-based practice guidelines. This all makes perfect sense, but what does this mean for providers and health systems? Documentation – which has always been important – is now even more critical than ever.
Documentation is Key
To earn the higher payment from CMS, providers first must document the patient’s condition using Hierarchical Condition Category coding (HCC coding) during a face-to-face visit – even if the condition has been previously documented in the EMR. Secondly, they have to document each and everything done to treat and/or monitor the patients’ condition – per the CMS value-based care requirements for each individual condition. This could be as simple as checking a box that the diabetic patient has had their required eye exam (even if the provider had NOTHING to do with performing the eye exam but is just verifying that it has been done), or it could mean documenting their routine blood glucose tests and/or medication regimen. If a provider misses any single one of these key steps, they earn no extra payment for the higher risk patient.
Another reason documentation is critical in a value-based world comes before the patient is even determined as qualifying for the higher risk adjustment payment. That’s because documentation of each condition, comorbidity, etc. using the appropriate codes for HCC coding will determine each patients’ risk adjustment factor (RAF) and ultimately, whether or not they qualify for the higher payment. Inaccurate HCC coding (which is done based on provider documentation) can result in millions of dollars in lost revenue.
How Technology Can Support Better Documentation
While there are plenty of gripes about the use of electronic medical records (EMRs) – when used correctly, they offer a powerhouse of data. You simply have to make the technology work for you – and not the other way around. One way to do this is to use analytics to help identify care gaps – are there diabetic patients in the EMR who have no documented foot or eye exams? Are there patients with advanced cardiovascular disease who aren’t on a statin? Reports such as these can help ensure that care gaps are closed and documented as such.
Similarly, many organizations use the EMR to add alerts or reminders to ensure providers document chronic conditions during each encounter. These simple alerts can serve as a fail-safe when appropriate documentation isn’t done.
Finally, partnering with an outsourced coding partner who is familiar with HCC coding and offers technology solutions such as real-time risk adjustment chart review and/or risk adjustment factor (RAF) score reporting can help organizations ensure they’re capturing the revenue they’ve earned for delivering higher levels of care.
GeBBS Healthcare Solutions understands that documentation in a value-based world is more important than ever. To learn more about GeBBS’ risk adjustment services and/or HCC coding solutions, visit our Payer Solutions. Or click here to Request a consultation.
