What Does an HCC Coder Do?

Chandra: So actually, all of these risk adjustment questions came in from the same person. And there’s a lot of good information to share here and it’s kind of hard to summarize it quickly, but I’ll try.

So what does an HCC coder do? Well, you’ll find that I tend to correct you if you say you are an HCC coder. You may be an HCC coder but you work in the field of risk adjustment. HCC is just one type of risk adjustment. This particular person said, “You know, I Googled HCC and it’s really just coding to the highest level of specificity, right?” Yes and no.

When we talk about risk adjustment and how risk adjustment differs from day to day coding operations in a physician practice, risk adjustment is based on chronic conditions affecting a patient, and trying to project based on all of the patient’s chronic illnesses now what kind of care they’re going to require next year.

And risk adjustment and HCC coders typically work for the insurance plan, usually, whether they work directly for the insurance plan as a subcontractor for a company working for the health insurance plan. There are more that are starting to work in a physician office, for a specific hospital or health group, but the vast majority of the time, at least historically speaking, they have worked for insurance companies.

And the reason for this is, let’s say I’m a physician and I report my claims to my Medicare carrier. I send in all my claims for my Medicare patients, and that Medicare carrier then pays me based on a fee schedule, whatever we’ve agreed to, whatever I’ve accepted contract on, accepted assignment, and that’s how I get paid.

Well, if the Medicare carrier that I’m billing to is a Medicare Advantage Plan — Humana Gold Choice, some of the Blue Federal plans, United HealthCare had some of these plans. There’s all sorts of different ones out there, but if they’re a Medicare Advantage plan, the purpose of a Medicare Advantage plan is a patient trades in their traditional Medicare Part A and Part B in exchange for this Medicare Advantage plan that covers everything and usually has a better deductible, better co-insurance, or offers some added benefit. Whether it be prescription drugs, a Silver Sneakers plan where they can go to a gym, different things like that.

Well, those Medicare Advantage plans, the way that they are funded, they’re funded by the federal government, but they get paid from the federal government not based on a fee schedule, not based on the CPT codes and RVUs like the physician typically does, but instead, they get based on a risk score. How risky is this patient? How much are they going to require in treatment next year? Based on everything that we’ve had to do for them this year and last year, how much are they going to cost us next year? How much are these chronic conditions getting worse, and are they going to need more care, are they need to see more providers? Those types of things.

What does an HCC coder do? So what that risk adjustment coder usually does or that HCC coder, is they have a list provided from that insurance carrier that says here are the chronic conditions that we get paid on and oftentimes, here’s the documentation that is required.  Because it’s not enough for a physician just to say, “Oh, in the medical history patient has diabetes.”

Did they address the diabetes in any way? Did they renew the medications? Did they tell them to keep taking their medicine? Did they ask them about their blood sugar levels? Did they do anything to evaluate systems that could be affected by the diabetes — the eyes, the neurologic system, the kidneys, all of those different pieces.

So really what an HCC coder is doing is reviewing the notes from a different perspective, instead of just saying what did you address, treat or what impacted your care today. Yeah, we want all of those things. But from a chronic condition perspective, what things may have affected the care and what things may have you addressed that you didn’t really spell out that you addressed in the assessment plan; and how can we help you better document those pieces. So yes, it’s all about level of specificity, but it really focuses on chronic conditions.

Whew…that was lot! I hope this helped clear up the question “What does an HCC coder do?”

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 “What does an HCC coder do” video segment originally aired on Live with Laureen #010.

Related HCC/Risk Adjustment Resources

• Risk Adjustment Bundle (RA + ICD-10 + MTA Courses)
• Risk Adjustment Full Course
• Risk Adjustment Review Blitz (Exam Prep)
• What Risk Adjustment Looks Like Today (Video)