HCCs: Whose “problem” is it? It’s an AND, not an OR!

February 26, 2018 / By Cheryl Manchenton, RN

HCCs are a “problem.” By that I mean no organization can ignore the impact of HCCs. No CDI specialist, HIM professional, quality specialist, provider or billing auditor can remain uneducated about the full impact of HCCs on their organization.

Recently, I was discussing the insufficient query for and capture of HCCs in a client’s inpatient setting. The organizational leadership was unconcerned and insisted they had a vigorous HCC program in both their outpatient and professional services settings, which included extensive training and education. This is excellent news…to a point.

Please understand, a vigorous education program and workflow for capturing HCCs in the outpatient setting is essential. BUT to believe it isn’t necessary in the inpatient setting is flawed reasoning.

Think of HCCs as similar to population health. The organization is responsible for the health and resource consumption of all patients they see—not just patients seen on an on-going basis in the clinic setting. So for those patients who are only seen in an inpatient setting (for example, if they are admitted once in a 12-month period), we have one chance to capture their acuity and resource needs. Do you really want CDI specialists, coders or providers to stop in the middle of their workday and perform a chart review to see if this patient is an on-going clinic patient? I didn’t think so. 

Let’s look at the other problem with thinking HCC capture is just for the outpatient setting: Patients like me!  I am certainly of the age where an annual physical is beneficial, plus I have a few medical conditions that should (note I said “should”) be monitored. Now, ask me the last time I had a basic physical.  Yes, I know health is important, but we nurses often say, “Do as we say not as we do!” Anyway, if I do not see my provider on a regular (or at least annual) basis, the organization with which my provider is associated is missing the opportunity to capture my HCCs.  And based on my work, which involves extensive review of medical records, I know I am not the only patient that may not be seen annually! Since we have many non-compliant patients (for various legitimate or illegitimate reasons), we need to capture their HCCs when they are inpatient.  And since the office setting is most likely only capturing chronic conditions, there are many HCCs for acute conditions that might only be documented in the inpatient setting.

Finally, let’s talk about provider behavior. Providers in the office see upwards of 20+ patients per day. To say they can perform a complete and careful review of all of a patient’s chronic conditions and document appropriately for complete capture would be unrealistic at best. During the hospital stay, the provider case load is a little lower and often shared among several providers, giving all the opportunity to fully document both acute and chronic conditions. 

Best practice is to make HCCs an AND (everyone’s problem) instead of an OR (just the outpatient staff’s problem). 

Cheryl Manchenton is a senior inpatient consultant and project manager for 3M Health Information Systems.