What risk adjustment coding is missing
For organizations committed to value-based care (VBC), capturing diagnostic integrity during patient visits is critical for accurate risk adjustment coding and fair reimbursement. Yet, many clinical teams still struggle to manage gaps between risk adjustment processes and provider engagement in the electronic health record (EHR), leading to missed or unaddressed Hierarchical Condition Categories (HCCs).
What’s to blame? Manual workflows, incomplete or cluttered problem lists, and rapidly evolving payer rules. These all increase the risk of missed HCCs, lower RAF scores, and increase the documentation burden for providers. The solution? Smart, in-workflow problem list tooling.
During a recent IMO Health virtual coffee event, a group of physicians, product experts, and value-based care leaders came together to discuss strategies to improve risk capture in EHR workflows, enhance care coordination, and leverage data-driven insights to boost patient care quality and maximize revenue in value-based arrangements.
As host Grace Vinton said, “HCC coding is very similar to our morning coffee… If you skip it, you can’t function, and neither can your RAF scores.”
Where risk adjustment coding breaks down
The panel, guided by IMO Health’s Steven Rube, MD, FAMIA, Chief Clinical Officer; Sriram Talluri, MBA, VBC Product Sales Director; and David Arco, Product Management Director, emphasized two common problems:
- Disorganized or incomplete problem lists
- Generic or imprecise ICD-10-CM coding at the point of care
“We see about a third to a half of problem lists are missing important chronic conditions, and often those missing chronic conditions are HCCs,” Arco said. “If the provider doesn’t see that the patient has a condition, then they’re not going to address it, and that is killing people’s RAF scores.”
If key chronic conditions are missing from the problem list – or if it’s rife with outdated diagnoses – clinicians are more likely to overlook conditions that impact risk scoring, quality metrics, and ultimately, patient care.
”It’s very important that not every diabetic looks like an E 11.9 for our coding friends, and that not every patient with CHF has the exact same class,” Rube said. “You need to document accurately.”
Precision is the bedrock of risk adjustment coding. Even small differences in ICD-10 coding can negatively affect reimbursement and revenue.
We see about a third to a half of problem lists are missing important chronic conditions, and often those missing chronic conditions are HCCs... that is killing people's RAF scores.
Why workflow optimization is essential for risk adjustment coding
Too often, the tools meant to help with HCC coding end up interfering with clinician workflows, causing frustration and inefficiency.
“I think this notion that doctors are averse to technology improvements is unfair,” Rube explained. “I think what doctors are looking for is something that doesn’t slow them down.”
Effective tools integrate seamlessly into existing EHR workflows and make it easier to find, address, and accurately document chronic conditions tied to HCCs.
“Don’t make doctors become coders. We’re not good at it. We’ll never be good at it. We don’t want to do it,” Rube stressed.
At IMO Health, we’ve had success pairing smarter problem list management solutions with natural language processing (NLP) that pulls insights from clinical notes.
I think this notion that doctors are averse to technology improvements is unfair. I think what doctors are looking for is something that doesn't slow them down.
Payer-provider collaboration key in risk adjustment coding
Risk adjustment coding isn’t a challenge specific to providers. Especially in Medicare Advantage contracts, payers have a vested interest in ensuring providers get paid.
“The payer isn’t really the payer – the government is,” Arco explained.
Integrating payer insights into the clinical workflow can help providers gain visibility into important HCCs.
“Providers need to know what to look for and need to be able to find it at the point of care,” Arco continued.
What success looks like in risk adjustment coding
Precise, timely HCC documentation has many benefits:
- More accurate RAF score calculations
- Greater visibility into patient complexity
- Stronger financial performance in value-based contracts
- Decreased documentation burden for clinicians
- Cleaner data for downstream initiatives like population health management
“You’re already doing the work, the patient is already this sick… you’re just not getting credit for what you’re doing,” Rube said.
Smart, integrated tools that work silently in the background are key.
You're already doing the work, the patient is already this sick... you're just not getting credit for what you're doing.
Finding the path forward
IMO Health’s value-based care solution surfaces real-time insights in the problem list, using prior encounters, unstructured EHR notes, and payer data to improve RAF score accuracy and care quality.
In a nutshell, our VBC solution can:
- Organize and streamline the patient problem list
- Identify chronic conditions buried in the chart
- Guide HCC specificity at the point of care
- Align payer insights with provider workflows
“It’s not a money and a budget and a people issue,” Rube emphasized. “If you don’t have the right tools at the point of care, you’re not going to have good data.”
