Many speak on the financial benefit in Hierarchical Condition Category (HCC) coding, but proper HCC documentation and reimbursement directly affects the patients. The patients are the most important factor, so proper documentation and coding is about more than just the financial gain.

Documentation is all about painting a picture of the patient and their health. It’s easy for clinicians to see patient outcomes in their real-time visits, but the non-clinician side doesn’t have opportunity. Non-clinicians have to rely on hard data like graphs, time frames, numbers, charts, and other things of that nature. Yet, these non-clinicians may not always be aware how to translate that in a big picture of the patient’s overall healthcare.

The provider’s documentation of a patient’s past medical history (PMH) is needed to know and understand the patient’s complete and often complex health status. Having this detailed, accurate information aids non-clinicians to get a deeper understanding of the patient’s past and present health needs, while achieving the most accurate coding. Complete and correct documentation is needed throughout every visit to maintain an accurate medical record for each patient, which goes from the time the front desk checks the patient in to the provider completing the visit and the patient leaves the office.

The accurate medical record bridges the gap between the patient and the non-clinician’s ICD-10 book. This will also aid to be sure Medicare Advantage (MA) will cover the patient’s necessary medical costs to be sure the patient isn’t paying out-of-pocket for anything they do not have to. Good documentation always goes hand-in-hand with good patient care.

If you’re interested in learning more about HCC and Risk Adjustment Coding, take MMI’s Risk Adjustment Documentation and Coding Course! Pre-Sale of the course begins July 1, 2019 and the course will be officially released on July 16, 2019. Learn more and sign up here: