Key takeaways:

• Accurate capture and understanding of Hierarchical Condition Category (HCC) codes are essential to a healthcare organization’s success in value-based care (VBC).
• Partnering with PINC AI™ Stanson’s clinical decision support (CDS) technology platform empowered a large health system in Missouri to significantly improve HCC coding accuracy by directly engaging physicians at the point of care in the Electronic Health Record (EHR) workflow.
• PINC AI™ Stanson helped the Missouri health system streamline and simplify the HCC coding process by incorporating real-time guidance for providers that empowers them to take immediate action.

It’s repeatedly said that engaging providers around clinical documentation is a challenge. In fact, time-consuming data entry is often cited by clinicians as a major source of professional dissatisfaction. Accurate risk adjustment is essential to both the clinical and financial success of a healthcare organization. The Centers for Medicare & Medicaid Services (CMS) uses the Hierarchical Condition Category (HCC) risk adjustment model to estimate anticipated costs for Medicare beneficiaries. The results directly affect the reimbursement healthcare organizations receive for patients participating in Accountable Care Organizations (ACOs) and Medicare Advantage (MA) plans.

Provider organizations are required by CMS to identify all qualifying conditions annually. Incomplete and inaccurate HCC coding can negatively affect reimbursement and hinder high-quality care. Gaps in care can emerge when the true severity of a patient's condition isn’t adequately assessed and documented in their medical record.

Considering these issues, it’s crucial to develop clinician engagement around HCC coding. This is a concept that staff at one Missouri-based health system understands all too well. The non-profit healthcare organization serving the greater St. Louis, southern Illinois and southeast Missouri regions is on a mission to improve their HCC coding accuracy.

“Over the past few years, we made substantial improvements in the recapture rate, but where we really found ourselves struggling was the initial capture. So, we wanted to find a way to improve our initial capture that didn't require hiring 80 more clinical documentation improvement specialists,” said the health system’s Medical Director.

The Missouri health system, which became the first healthcare provider in their area to take on the challenge of forming an ACO, experienced a common HCC coding problem: their clinicians didn't fully grasp the nuances of risk coding. “Even though providers play a crucial part in HCC coding documentation, the complexity of coding shouldn't be put solely on their shoulders. We are working to provide solutions that are as simple as possible for providers so that they can spend more time interacting with patients and less time reading Excel spreadsheets,” said the Medical Director.

Equip Providers with the Right HCC Coding Tools

Providers must be given the right HCC coding tools in order to simplify clinical documentation. Electronic health records (EHRs) don’t provide sufficient capabilities for optimal HCC coding, so adopting a technology that simplifies, automates and improves documentation accuracy is essential to a good provider experience and a successful journey in value-based care.

The Missouri health system turned to PINC AI™ Stanson for an integrated solution that provides clinical decision support (CDS) in the EHR environment. “We didn't want to add a profound burden and alert fatigue to the providers, and we wanted a solution that was available inside their already-existing workflow in the electronic medical record (EMR). We did survey the market and Stanson was the best solution we identified that could hit all our requirements,” said the Medical Director.

PINC AI™ Stanson HCC alerts provide automated and simplified HCC coding guidance to providers at the point of care for assistance with a provider’s accurate and appropriate HCC diagnosis capture. The Missouri health system used a measured approach when the HCC alerts were first activated and only sent a subset of alerts to their primary care providers (PCPs).

“We awaited feedback that really helped us optimize the alerts themselves such as if the alerts were firing at the correct times. After a few months, we proceeded to roll out additional alerts to more PCPs before expanding to specialists,” said the Missouri health systems Clinical Documentation and Quality Supervisor. The entire PINC AI™ Stanson HCC library has been rolled out by the health system leadership to their PCPs and specialists.

HCC Coding Education is the Best Kept Secret

Having the right tools is a huge factor in improving a provider’s HCC coding accuracy. However, even the best tools won't work without everyone’s participation in keeping providers interested in HCC coding improvements. So, how can healthcare organizations encourage clinicians to take part in HCC coding? The answer is education.

Healthcare leaders must make sure their team is aware of the potential impact of HCC coding initiatives if they want to see meaningful improvements. It’s wise for decision-makers to share details with their team of how increased coding performance could impact their organization.

“We try to grab providers’ attention in various ways. It can be webinars, emails with tips called out in them and even hard copies of tip sheets that can be seen in the ambulatory setting. So, we do try pretty much every avenue to get in providers’ faces, if you will, and really continue educating repeatedly,” said the Clinical Documentation and Quality Supervisor.

Track HCC Coding Efforts Over Time

Establishing a baseline of which to measure from is crucial. Healthcare organizations must develop a simple system to track efforts if they want to be able to assess improvement. Making HCC efforts measurable enables decision-makers to identify areas where their staff is falling short swiftly and easily. “Obviously, engaging providers is the number one difficulty with coding. So, we tried to design a system where we could provide them with feedback that was useful without being overwhelming or negatively perceived,” said the Medical Director.

One great way to do this is with the PINC AI™ Stanson data analytics platform. PINC AI™ Stanson allows healthcare leaders to investigate every alert to see when it fires, which clinicians received the alert and how many times the alert is launched. PINC AI™ Stanson also gives healthcare leaders the ability to see which alerts were ignored or if an alert is followed at a high rate.

“We then discuss this information at meetings with clinicians. Providers are fairly competitive, so when they notice that their peers are following alerts twice as often or three times as frequently as they are, it naturally sparks conversation.” said the Medical Director. “We’re also able to clarify any misconceptions or questions, some of which might be regarding the tool in the EMR, and others might be connected to a lack of understanding of coding in general.”

As a result, the Missouri health system expects the program to make a big impact. “We're currently going back to match the patients with their particular VBC plan and calculating the HCC and RAF changes to come up with a true ROI, but the revenue impact may be more than $4 million for our population,” said the Medical Director.

Final Thoughts

Healthcare organizations will experience improved HCC coding when clinicians take a proactive role in documentation. PINC AI™ Stanson aims to help increase provider engagement without causing alert fatigue by seamlessly integrating with EHRs and utilizing automation to educate clinicians through the documentation processes with useful insights specific to each patient at the point of care.

“Comparing PINC AI™ Stanson to some of the other initiatives that we've done, provider feedback was much more positive than most things that we do, and the magnitude of improvement was pretty substantial,” said the Medical Director.

Healthcare leaders can pinpoint specific barriers and take targeted action to remove them in order to increase clinician engagement around documentation. Whether it’s through new technology or more education, there are strategies to advance and guarantee that HCC coding isn’t put on the back burner.

For more on this topic:

• Learn about what a partnership with PINC AI™ Stanson can do for your healthcare organization.
• Discover how members are achieving great results with PINC AI™ Stanson.

About the Authors

Ryan M. Nellis

Vice President & General Manager, Stanson Health, a Premier (PINC) company

Ryan leads a team of clinicians, engineers and data science experts who work together to deliver AI-infused solutions to improve patient care and health costs via a growing client network of over 650 hospitals and 400,000 physicians.

Mr. Nellis is a growth-oriented leader who delivers business value in investor/venture and PE-backed, high-growth, public and private companies. He has developed and executed strategies in the health analytics and real-time clinical decision support solution markets – from both the provider and payer perspectives.

Jennifer Pratscher

Senior Customer Success Director

Jennifer Pratscher is the Senior Customer Success Director at Stanson Health, a Premier Inc Company and is responsible for driving clinical & financial outcomes within Stanson customer organizations. Utilizing her knowledge & expertise in Clinical Decision Support governance, she aligns Stanson’s solutions with the customer’s strategic initiatives in order to deliver value & return on investment.