HCC & Risk Adjustment
At Wave Online. we pride ourselves on our proven track record of accurately coding millions of charts with a remarkable accuracy rate of 95% and higher. Our exceptional completion rates in Medical Record Retrieval, Medical Billing, and Coding drive superior clinical and financial outcomes for your organization.
Our team of record retrieval experts operates robustly, having successfully completed over 2 million chart extractions, setting the industry standard for precision and accuracy.
Medicare HCC Services
- Part C and Part D HCC coding
- Comprehensive retrospective, concurrent, and prospective chart review processes
- Annual validation (all unique ICDs or HCC categories) and encounter-specific coding (all ICDs or all HCCs per encounter)
- Projects for identifying claims gaps and suspect HCCs
Medicaid CDPS Services
- CDPS, Rx (UCSD) coding
- Thorough ICD coding with a focus on Social Determinants of Health (SDOH)
- Hybrid coding models (HCC+CDPS)
HHS HCC Services
- Project-based coding for each day of service (DOS)
- Specialized coding for pregnancy complications and delivery charts
Physician-Based Coding Services
- Real-time HCC coding services in a concurrent prospective environment
- Clinical Documentation Improvement (CDI) and physician education
- Coding expertise in CPT, HCPCS, and ICD
- MIPS and APM measures to enhance physician incentives
Hospital-Based Coding Services
- Assignment of ICD-10-PCS and ICD-10-CM codes
- Use of ICD-10 codes to determine Medicare severity Diagnosis-Related Group (MS-DRG)
HEDIS Measures
- Evaluation of Care Effectiveness
- Access to Care and Availability
- Patient Experience
- Utilization and Risk Adjustment
- Health Plan Details
- Data Collection via Electronic Clinical Data Systems
ACO Measures
- Extraction of measures for MIPS, APMs, and MVPs to report quality metrics
- Promotion of interoperability
- Performance improvement activities
- Cost analysis
Claims Gap Analysis
- Analysis of year-over-year claims submissions for members
- Reviews to identify missed/dropped HCCs
- Development of a database for suspect HCCs
Suspect Logic
- Hypothesis-driven predictive modeling
- Development of suspect logic
- Logic-based reviews for retrospective and prospective coding
Medical Record Retrieval
- Extraction of quality measures across key domains:
- Patient and Caregiver Experience
- Care Coordination and Patient Safety
- Clinical Care for At-Risk Populations
- Preventive Health Services
Front Desk & Appointment Management
- Appointment scheduling and management
- Verification of patient information
- Coordination with healthcare departments and professionals
- Appointment reminders and outreach
Prospective Risk Adjustment
Reviewers play a critical role in assessing a patient’s full medical picture, including past HCC codes, prescription medications, hospital records, lab results, and doctor’s notes. Often certified risk coders, they scrutinize these diagnostic details to ensure precise coding, gauge each patient’s health risk, and provide providers with a list of potential HCC diagnosis codes for consideration during their appointments. This review process not only helps healthcare providers craft targeted treatment plans for upcoming visits but also assists payers in forecasting costs for the next year based on historical data. Accurate information is key to calculating premiums and reimbursements accurately, ensuring that financial planning aligns with patient care needs.
Advantages:
Proactive Care: Prospective risk
adjustment promotes a forward-thinking approach to healthcare by
predicting risk scores early on. This encourages physicians to
address conditions sooner, leading to improved patient outcomes
through early interventions.
Financial Predictability: Prospective coding improves financial
predictability for healthcare organizations. It facilitates
better budgeting and resource allocation by providing expected
risk scores at the start of the year.
Limitations:
Changing Health Status: Prospective coding may not fully reflect changes in a patient's health throughout the year, as it is based on initial assessments. Its effectiveness depends on the accuracy and timeliness of the patient data used.
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