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HCC capture: How to engage specialists and succeed in value-based care


    Specialists must be part of any value-based care strategy going forward to meaningfully reduce costs and improve population health. But it’s difficult to know where to start. Begin those efforts with one ‘no regrets’ strategy—engaging specialists in accurate HCC capture.

    Hierarchical Condition Categories (HCCs) are groupings of ICD-10 diagnosis codes for active and chronic conditions. Medicare and other payers use HCCs to calculate patient risk scores and predict costs, which inform provider organizations’ reimbursement and performance benchmarks. Put simply: If ICD-10 codes aren’t coded correctly and HCCs underrepresent disease burden, reimbursement will be lower and quality benchmarks will be more difficult to achieve in shared savings programs.

    And it isn’t a one-time action—diagnosis codes must be updated every 12 months. Otherwise, CMS does not count them.

    The future of value-based care

    Medicare and Medicaid risk is progressing (slowly) — but commercial risk will determine whether the industry tips toward a new cost and quality standard.


    Why engaging specialists in HCC capture is ‘no-regrets’

    Historically, it has been the PCP’s responsibility to accurately capture HCCs—after all, they manage many of the patients with chronic conditions upon which HCCs are built. But it’s time for organizations to move past this “first wave” of HCC capture and take the next step—by engaging specialists in HCC capture. Here’s why:

    • HCC capture introduces specialists to a population-based approach to care. Organizations have to start involving specialists in value-based care. Identifying complex chronic conditions helps specialists become more aware of the need to manage them to control costs and improve patient outcomes.
    • It gives specialists credit for the increasingly complex patients they’re treating. HCC capture is not a primary care-only issue. The chronic disease burden is growing, with the number of adults with three or more chronic conditions expected to almost triple by 2030. Provider organizations need all physicians involved to ensure appropriate compensation for the high-risk beneficiaries they’re already treating. As we know, not doing so leaves money on the table. Not only does HCC documentation drive short-term reimbursement rates (such as care management codes) but also future performance benchmarks (for MSSPs and Next Gen ACOs).

    Four imperatives to engaging specialists in accurate HCC capture

    The good news is it’s not all that different from what you’ve previously done with primary care. As an executive, take the lessons you learned from there—successes and failures—to help inform your approach toward specialists.

    Below are four key imperatives we’ve identified for engaging specialists in accurate HCC capture:

    • 1. Start by scoping specialists’ role in HCC capture.
    • 2. Educate specialists on the importance of accurate HCC capture.
    • 3. Tie rewards to HCC capture.
    • 4. Provide specialists with coding support.

    Parting thoughts

    As you engage specialists in HCC capture and iterate on solutions, continue to reflect on what’s worked and what hasn’t in primary care. Because while specialty care is a different space, the overarching lessons of engaging physicians in HCC capture remain largely the same.

    HCC capture is an important first step. But it can’t stop there. Moving forward, specialists will play a critical role in whether organizations succeed in value-based care. Our team is conducting ongoing research into ambitious, yet feasible ways to involve them in that care transformation. Have thoughts? Send them to

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