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HCC Auditing: Identifying Lost Revenue Associated with Skeleton RAF

by Rose T. Dunn, MBA, RHIA, CPA, FACHE

Why are physician practices reluctant to code all conditions? I still see physician offices submitting claims with only four diagnoses (sometimes fewer).

The limitation of linking four conditions to a test or service has been interpreted by some providers as a limit on the number of diagnoses to report. Additionally, some payer systems restrict the number of codes they take from the claim, reinforcing the impression that a minimum number of diagnoses is sufficient.

In the world of HCCs, every condition being assessed should be documented as it may impact the rate of reimbursement. I think there is a real opportunity for coding professionals to engage their physicians in documenting all the conditions they address when they assess a patient. Identifying the lost revenue associated with a skeleton risk adjustment factor (RAF) rather than one that is fully populated with all the conditions the physician is treating is an effective way to make the case for improving the quality of documentation from your providers.

I’d be interested in hearing from physician practice coders on how they encourage providers to fully and completely document all conditions seen when assessing their patients. How do you deal with the situation of under-documenting?


Introduction to HCC Coding
Complete and accurate coding for Hierarchical Condition Categories (HCCs) presents an opportunity for improved data quality and appropriate reimbursement. Learn how from nationally recognized HCC expert, Rose T. Dunn, MBA, RHIA, CPA, FACHE.



Rose Dunn is the Chief Operating Officer of First Class Solutions, Inc., a healthcare information management leader since 1988, offering professional consulting services in health information management operations and information governance issues, as well as coding support, coding quality reviews, privacy/security guidance, temporary (interim) management, revenue cycle oversight, and accreditation preparation. Rose jumped into the weeds of ICD-10 more than 10 years before it was implemented and has been getting back into the weeds of HCCs for the last 2 years. Rose is the author of “The Revenue Integrity Manager’s Guidebook” available from the National Association of Healthcare Revenue Integrity and other books on Coding Management and Auditing from HCPro. She is assisting Libman Education in the development of an HCC educational program. Ms. Dunn holds a B.S. and M.B.A. from Saint Louis University. Contact Rose at 314-209-7800 or [email protected]

About the Author

Libman Education
Libman Education Inc. is a leading provider of training for the health care workforce offering self-paced and instructor-led online courses designed and developed by leading industry experts in Health Information Management (HIM) and Medical Record Coding. Our courses are specifically designed to improve individual skills and increase the efficiencies and competencies of health care providers and institutions. At Libman Education, we understand the needs and challenges of a well-trained workforce and offer the right-mix of online education to ensure that the health care professionals are prepared to meet the challenges of the changing workplace.

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