Performing HCC Risk Audits

Setting up Audit Guidelines

Scope of Audit

Check the HCC box under scope of audit
Check the appropriate Risk Adjustment Models
RXHCC (Medication)
ESRD (End Stage Renal Disease)
V21 (Medicare Advantage – 2017 DOS)
V22 (Medicare Advantage – 2018 DOS)
V23 (Medicare Advantage – 2019 DOS)
V24 (Medicare Advandage – 2020 DOS

Audit Parameters/Guidelines

Allow > 4 Diagnosis Codes – set to YES
If performing strictly HCC Audits without E/M codes:
Chief Complaint Required – set to NO
Chief Complaint Description Required – set to NO
Infer Chief Complaint if not stated – set to NO
HPI Documentation required by provider – set to NO
Medical Decision Making (MDM) Required - set to NO
Run Edits Required – set to NO

Assign Report Parameters

Set your report type (samples at end of document)
HCC/Risk Adjustment Standard Report – this is for HCC only audits
HCC/Risk Adjustment Combo Report – this is for HCC & EM/Surgical audits combined.
Project Details Report – Practice Score – check the HCC box
Include HCC Description – set to YES
Include HCC Risk Score – set to Yes

Note: Audit Manager does not calculate the risk score - this is an open text field to be filled out by the auditor. The Risk Score field (if enabled in the Audit Guidelines) will display below the CPT scoring section in the Audit Box. In addition to the ICD-10-CM codes, there are specific elements such as Medicare eligibility used in the calculation of the risk score, most of which are not captured in the normal professional claim audit, therefore, calculating the Risk Score falls outside the scope of Audit Manager.

Once HCC Auditing has been enabled in the Audit Guidelines, two new columns will appear in the ICD/EM/CPT/HCPCS Codes scoring section of the Audit Box.

If the audited ICD-10 code is correct, use the copy to audited quick click to walk the code across the columns. If incorrect, type the correct code into Audited and Risk Adjustment ICD-10 columns.

Depending upon the risk adjustment models selected in the audit guidelines, the correlating Risk Adjustment Codes (RAC) will pull into the Risk Adjustment Code column.

If the ICD-10 code is not a risk code, an N/A will be displayed in the Risk Adjustment Code column.

HCC Risk Audit Reports

The report samples are designed to demonstrate the different code tables on the front page and columns in the chart tables on subsequent pages for each report type.

Risk Adjustment Standard Report – used for HCC only audits

HCC/Risk Adjustment Combo Report – this is for HCC & EM/Surgical audits combined