lMedicare Advantage (MA) has more than doubled in enrollment over the past decade, with half of all Medicare beneficiaries (50.4%) participating in the plan. Why does this matter? To receive optimal risk-adjusted reimbursement under the MA plan, providers must code with the utmost specificity and capture all relevant hierarchical condition categories (HCCs).
Precise coding creates a more accurate ‘digital twin’ in the electronic health record (EHR), which boosts the value of individual problem lists, supports care team collaboration, and improves chronic disease management — it’s a pillar of value-based care.
The problem? Most electronic health records (EHRs) fail to capture the necessary level of specificity. Over time, this can amount to the loss of millions of dollars in additional Medicare Advantage dollars.
Our latest insight brief covers the financial benefits of integrating advanced problem list tooling into provider workflows, including a relevant case study with impressive results.
INSIGHT BRIEF
A proactive approach to HCC management for better risk-adjusted reimbursement
Short on time? Keep reading for a preview of the insight brief.
Improving diagnosis specificity
Beyond problem list improvements, ICD-10-CM refinement tools integrated into point-of-care workflows help providers diagnose conditions with maximum specificity. This is vital because, as discussed above, the greater the level of specificity, the higher the RAF score – which translates into increased reimbursement. Unfortunately, not all native EHR diagnosis tools are optimized to capture the necessary level of detail.
However, with robust, continuously maintained clinical terminology fully integrated into the EHR, providers can view which SNOMED® CT and ICD-10-CM codes are mapped to a problem, ensure that multiple ICD-10-CM codes are included where appropriate, and see which problems have associated HCCs. IMO Health’s problem list tooling leverages this type of terminology – built by experts over 30 years, encompassing countless ways to describe patient problems and treatments, and meticulously linking clinician-friendly terms to standard codes.
To keep reading and learn how precise HCC coding can maximize revenue and support value-based care in 2025 and beyond:
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