Can I Be Eligible for HCC Work as a CPC-A?

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Chandra: Can I Be Eligible for HCC Work as a CPC-A? Absolutely. And we’re actually seeing a lot, a lot of risk adjustment groups, risk adjustment prospective employers that are hiring CPC-A’s, and they do it for a couple of reasons:

One, you don’t have any bad habits that I have to teach you to do the opposite of. I don’t have to get rid of them.

The other is that almost all risk adjustment prospective employers provide training of their own because each health plan is slightly different and there are a little different rules.

So while I can teach you the kind of the basics of risk adjustment, how it works, and what Medicare says here are the rules, each health plan may have a little different interpretation of what qualifies as appropriate documentation. So, they’re actually going to teach their employees “I want it done this way and here are the explicit rules you have to follow for us on this plan.” And sometimes if you work for a third party billing organization that subcontracted with one of these carriers, you may have to learn multiple different plans, right? If it’s Anthem, you do this. If it’s Aetna, you do this. You know, depending on what their rules are.

Laureen: And we’re finding too that… I don’t want to reveal too much, but anyway, we’re talking with a large group that employs risk adjustment coders, and for years, they always wanted them to get their CPC®. Well now, with the new CRC® credential they’ve recently changed their policy to where now they want them to get the CRC®. So, you know, Chandra has always said that you don’t have to get your CPC® and then do CRC®. You can actually go right to the CRC® and not even really mess too much with the CPT manual and focus on ICD-10 and risk adjustment.

Can I Be Eligible for HCC Work as a CPC-ASo, we’re actually going to be releasing, I think, in tomorrow’s newsletter a risk adjustment package that includes our full ICD-10 course, plus our risk adjustment course, which goes over all the, you know, basically non… Well, encoding concepts as well, but the two together are great. So a brand new person in the industry could actually do those two courses, take the CRC®, and go look for these prospective employers that are looking for risk adjustment coders and be very well trained. So that’s very exciting, I think. And then you only have to worry about one code set, right?

Chandra: Right.

Laureen: Get one code set in your brain.

Chandra: We actually have somebody in the Facebook chat. Barbara completed our class and she’s actually working in the risk adjustment field. And she said it’s a lot of different things, everyday there’s something new. And she’s one of those that works for a third party. So she’s dealing with a different plan at different times and the rules really do change. That’s why I say when when you attend a course, anybody’s course, whether it’s ours or somebody else’s on risk adjustment,  we can’t teach you everything. We can give you the benefit of our experience, we can teach you how the code set works, what the codes are that risk adjust for the different plans, whether it’s Medicare or whether it’s the HHS plans. And sometimes even the CDPS codes that adjust. But again, those vary by state.

But it really comes down to which specific plan you’re working with and what their rules are, what they feel is good and what they feel is not good, and it may differ greatly from the plan next door, and what they’re doing.

Laureen: What I’m noticing in the industry in all the years that I’ve been around is that things are shifting from just being a coder, you know, like translating a medical document into codes into really understanding the bigger picture and understanding the reimbursement structure behind it, so that you can be more effective at your coding.

It’s just like when I was in high school learning calculus or whatever, you could plug the formula in and maybe get it right all the time, but until you really understood why the formula worked, you didn’t get that aha moment, you know, and it’s the same with coding.

When we understand why for outpatient we do it differently than we might do it for inpatient, then it all gels and makes sense, and you can be an adviser to the providers that you’re working for, you can catch mistakes, you can see opportunities left on the table that the the provider was entitled to reimbursement for, and the opposite, protect them if they’re doing practices that would get them in trouble in an audit. And so, that’s the the trend that you know is really happening where coders are actually getting… their roles are becoming more elevated in what we’re doing. We’re doing a lot more auditing and things like that.

So, really understand the payment methodologies. Even if you don’t work in the particular setting, it’s important to understand at least from a general sense how they work and even so much so on the CIC exam which is the inpatient credential. They do ask you some outpatient related questions and vice- versa. On their COC exam, which is certified outpatient coder, they ask you a few inpatient questions to make sure. At first it really bothered me. I’m like, outpatient should be outpatient, and inpatient should be inpatient. But really, to be good at either of those roles you should have a little bit of knowledge of the other one.

Chandra: Well, and to kind of dovetail onto that, risk adjustment in particular, I can’t tell you how many providers Medicare Advantage patients and are contracted with Medicare Advantage plans but have no idea how the payment structure is different for those, because what they see, “I’m paid on a fee schedule. I don’t care about diagnosis. It doesn’t impact me,” until somebody explains to them.

The way that the insurance company who is paying you on this fee schedule, the way they get their money is based on the diagnoses you document. So, if you see that your fee schedule is being reduced, that you’ve got insurance carriers that are dropping you — Because we’re seeing this, they’re calling it narrowing networks, right? They’re getting rid of those physicians who aren’t doing what they need them to do, so that the insurance company can get the reimbursement they need from the federal government. If the physician is not doing their part, what’s the easiest way for the insurance company to fix that problem? Well, drop that physician, right? Find a physician who documents appropriately so that we can get our money, so we can afford to pay that physician.

Really, once you explain that to them and they start to see the big picture, that’s when they have the ‘aha’ moment as well, and you’ll begin to see improved documentation, you’ll begin to see physicians who do worry about diagnosis coding, and they start asking those questions.

Long before I got into the world of risk adjustment, I would have people say, “You know, my physician doesn’t think there’s any value in diagnosis coding and being specific,” especially when we were still in ICD-9. It was a much more vague code set. There weren’t a lot of specific options. Providers would document very broad diagnoses. And what I would always tell them is, you know, talk to your physicians, and the minute that they say that they’re upset that the hospital can’t afford the equipment that they want to use to do a test, remind them. Their documentation, specifically their diagnoses, contributes to what that hospital is able to bill. Give them that big picture, and you’ll see some improvement, you’ll see some changes.

Whew…that was lot! I hope this helped clear up the question “Can I Be Eligible for HCC Work as a CPC-A?”

If you’re interested in pursuing a career in Risk Adjustment, CCO offers a full course on Risk Adjustment as well as a CRC Review Blitz for exam preparation.

The “Can I Be Eligible for HCC Work as a CPC-A?” video segment originally aired on Live with Laureen #010.

Related HCC/Risk Adjustment Resources

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