HCC (Hierarchical Condition Category) codes are a subset of ICD10 codes that Medicare (and increasingly commercial payers as well) uses to determine the risk scores of Medicare Advantage patients. The sicker the patient, the more HCC codes they have, and the higher the risk score. The higher the risk score is for a patient, the higher the predicted expenditure and therefore the higher the payment to the health plan for that patient.

1. Solving The Challenge of Real-Time
HCC Coding for Providers
Down in the trenches of Medicare Advantage primary care, most providers in the
business know the importance of HCC coding. However, for the busy practitioner
who is taking care of the patient and dealing with an alphabet soup of mandates
such as HEDIS, STAR, HCAHPS, etc, it is quite a task to pay attention to HCC coding
in real-time. As a result, providers fall short and have to answer then queries from
coders re HCC codes that may have been missed.
The answer to this problem may lie in an EHR- integrated tool which can provide
real-time HCC medical coding guidance to the provider. Such a tool would
intelligently analyze the chart as the provider is seeing the patient and suggest
appropriate HCC codes. The provider could then add the codes and plan of care to
the encounter, before leaving the exam room. We believe we have built just such
a real-time HCC coding software tool called HCC Assistant. This application is
integrated with multiple EHRs and through the integration, it can receive patient

2. data in real time, analyze it against intelligent rules, and suggest HCC codes,
within seconds. It can analyze structured and unstructured data, which is great for
folks who free-text their notes. It can also look at lab results, imaging results, etc,
so it is analyzing the entire chart, not just encounter notes.
For those not familiar with HCC medical coding and risk adjustment. HCC
(Hierarchical Condition Category) codes are a subset of ICD10 codes that
Medicare (and increasingly commercial payers as well) uses to determine the risk
scores of Medicare Advantage patients. The sicker the patient, the more HCC
codes they have, and the higher the risk score. The higher the risk score is for a
patient, the higher the predicted expenditure and therefore the higher the
payment to the health plan for that patient. As one can imagine, if a patient’s risk
score does not reflect the patient’s condition due to inadequate coding, it can
affect the plan’s bottom line and by extension the physician’s profile. Proper HCC
medical coding is therefore critical.
We are hopeful that this intelligent HCC coding software tool will help providers
and their billing staff to do appropriate HCC coding which in turn will lead to
accurate risk adjustment at CMS and health plan levels.