What new healthcare career opportunities do you think will emerge for coders who understand risk adjustment?
Hierarchical Condition Categories (HCCs) are utilized by Medicare Advantage and Affordable Care Act payers for approximately 30 million individuals currently. Use of HCCs is projected to grow significantly in coming years and individuals with in-depth knowledge and command of the HCC system will be needed to ensure coding is accurate, supported by documentation, and that reimbursement is appropriate. We asked six experts what they thought about the challenges and opportunities provided by the accelerating move toward risk adjustment payment models.
In the fourth installment of this discussion, the experts discuss what new healthcare career opportunities might emerge for coders who understand risk adjustment. (See the series in its entirety here.)
DUNN: Risk adjustment emphasizes ICD-10-CM and is therefore an excellent opportunity for coders who don’t want to venture into surgical coding. I also believe that HCCs provide an opportunity for ambulatory CDI specialists—a role that is well-suited for coders. In the practice setting, CDI must be done concurrently or even before the patient arrives.
“IT staff can run the numbers, but only coders can explain the meaning of the clinical data.”
-Bonnie S. Cassidy
CASSIDY: I think several roles will emerge or are already in existence. These include HCC coding auditors, directors of revenue integrity, ambulatory CDI specialists, and directors of revenue cycle transformation. The industry also needs individuals who understand documentation and coding who can work in analytics. IT staff can run the numbers, but only coders can explain the meaning of the clinical data.
MALONE: New career opportunities include physician educators as well as pre-visit and post-visit claim reviewers to ensure accurate HCC capture. In addition to the obvious code-based opportunities, CDI roles are also an area of opportunity for experienced coders with enhanced continual education. Another area of opportunity is with provider systems that have an Accountable Care Organization. Risk adjustment is a key component to accurately budgeting for this population.
“HCCs present a new auditing role for coders…”
TAYLOR: HCCs present a new auditing role for coders, and I think organizations may eventually create two types of auditing roles—one for HCCs and another for non-HCC coding. Another opportunity is working as a subject matter expert for technology vendors, building edits for software and updates or overseeing product development.
“…there are many opportunities for coders with knowledge of risk adjustment to move up career-wise in their organizations. ”
MURPHY: I think there are many opportunities for coders with knowledge of risk adjustment to move up career-wise in their organizations. The risk adjustment market is vast, and there are few people who have knowledge of risk adjustment—even fewer with knowledge of coding for DRGs and risk adjustment. Physician educators who can analyze data and provide physician-specific training will be in demand.
JOHNSON: One emerging role will be HCC clinical documentation improvement (CDI) specialist—someone who can help physicians capture all diagnoses that affect patient care—and report those conditions every year (when appropriate). This type of CDI work is already happening in large network-owned physician practices, and it will continue to expand into all practices as physicians become even more overwhelmed with the administrative side of healthcare. Whether the CDI specialist is embedded within each individual practice or at the corporate level overseeing multiple practices may vary from organization to organization.
Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS, President of Cassidy & Associates
Rose T. Dunn, MBA, RHIA, CPA, FACHE, Chief Operating Officer, First Class Solutions, Inc.
Laurie M. Johnson, MS, RHIA, FAHIMA, Senior Healthcare Consultant, Revenue Cycle Solutions, LLC
Donna Malone, CPC, CRC, Director of Coding and Provider Education, Enterprise Risk Adjustment, Tufts Health Plan
John Murphy, MBA, Principal, Risk Adjustment Consulting
Earshler Taylor, RHIA, RHIT, CCS, CDIP, CPC-I, COC, CPC, Chief Executive Officer, Earshler Taylor Consulting
Lisa A. Eramo, MA, moderator and freelance writer
Fundamentals of HCC Coding
Go beyond just the diagnoses — really understand the methodology behind HCCs! Prepare for the future of healthcare reimbursement with “Fundamentals of HCC Coding,” by nationally recognized HCC authority Rose T. Dunn, MBA, RHIA, CPA, FACHE. Learn more here.