Why PCPs Should Focus on Coding and Documentation in Value-Based Care Programs

Hassan Rifaat, MD

Many PCPs remain in the dark when it comes to effective documentation, coding, and risk adjustment for their Medicare Advantage patients.

Each year, a growing number of providers are entering value-based care arrangements, including primary care providers (PCPs). Given their holistic view of patients, PCPs are the best types of clinicians to drive value-based care. Medicare’s Primary Care Transformation programs and many payer-developed value-based care contracts are proof of the move for PCPs to be at the center of this transformation and ultimately at the center of the care experience — right where they belong.

While the shift may be underway, many PCPs are not well prepared to operate successfully in these new arrangements. Currently, 67% of Humana’s Medicare Advantage members receive care from a PCP in a value-based care agreement. And yet, many PCPs remain in the dark when it comes to effective documentation, coding, and risk adjustment for their Medicare Advantage patients, all of which help drive value-based care outcomes, and income.

So how does a PCP take control of their value-based care success? One answer is accurate assessment and reporting of a patient’s clinical needs so that value-based payments will align with the necessary care delivered to that individual. By making documentation and coding activities a physician-driven priority in their practices, PCPs can receive the payments they need to close care gaps, leading to better outcomes and ultimately value-based care success.

How Coding Impacts Value-Based Care Outcomes and Income

Coding and documentation are the languages of our healthcare ecosystem. If the PCP’s documentation is lacking in any way—incomplete, wrong, or inaccurate ICD-10-CM codes—the revenue under value-based contracts can be severely impacted, and patients may not get the care they need.

In that scenario, patients may be omitted from beneficial care management, disease intervention, and other wellness programs. For example, a patient coded with uncomplicated diabetes may not receive the appropriate health plan services, but a patient coded with diabetes and related comorbidities would.

But who owns this process? The answer, for some, is a third-party service visiting the patient in their home or someone looking at a medical chart after the patient visit. In both cases, the coding and documentation are incomplete or inaccurate and often miss nuances that should be treated or followed up on. In reality, the PCP—the individual who knows the patient best and who can holistically capture all medical conditions or complications—should own that responsibility.

Proper documentation isn’t simply good practice; it is critical for value-based care. PCPs in value-based care arrangements must comply with reporting standards for risk adjustment and quality of care that require more detail than simple claims submission rules under fee-for-service models. This robust documentation, combined with appropriate ICD-10-CM coding, provides a comprehensive view of the patient, which leads to better and more cost-effective care — the marks of successful value-based care.

Thinking deeply about documentation and coding in relation to payments may be new for some physicians. But as risk shifts to providers, health plan concepts like “risk adjustment” become more relevant to PCPs, as these traditionally “payer activities” benefit both plans and providers. In risk adjustment, Hierarchical Condition Category (HCC) codes and other data are used to create a Risk Adjustment Factor (RAF) score to predict the costs for a patient’s care in a specific benefit year.

These RAF scores reflect the PCPs’ level of documentation and coding to support the applicable conditions in the HCC model. Accurate risk adjustment ensures that payers with sicker patients and multiple chronic conditions receive higher capitated premium payments. Because of medical loss ratio limitations, most of these Medicare premium dollars have to be reinvested into benefits for care, resulting in more resources for PCPs to draw from to achieve better outcomes and earn value-based care rewards.

Improving Coding Without Burdening the Practice

Despite the benefits of value-based care compared to the legacy fee-for-service model, the transition for most PCPs is not easy, because the systems surrounding them have yet to catch up. A lack of complete and robust data presents a challenge in optimizing coding, documentation, and outcomes. To get the full scope of a patient, providers must synthesize health plan data with all relevant EHR data, some of which is hard to use because it is unstructured or not easily accessible.

Additionally, accurate diagnostic coding and quality reporting is labor-intensive and is predicated on a complex set of rules that frequently become a stumbling block for practices that lack time, staff, tools, and coding expertise. Some PCPs employ medical coders, but few possess the highly specialized skills needed to code to appropriate specificity required for value-based care. Instead, PCPs often rely on their EHR as the sole record keeper or invest in new technology or consultants, ultimately forming a patchwork solution that paints a still-incomplete picture.

When looking for solutions to support better documentation and coding, PCPs should remember the aim of value-based care and opt for holistic approaches. Providers need computer-assisted diagnostic coding technology and clinical decision support to take the guesswork out of coding.

Coupling these technologies with clinical and administrative staffing resources has emerged as a strategy to offer PCPs both the tools and talent they need to succeed. When properly supported, PCPs can focus on caring for all the needs of their patients. By capturing the full clinical picture as accurately as possible through proper documentation and coding, PCPs can ensure they have the right resources to best serve their patients and earn the commensurate rewards for high quality care in this new value-based care world.

Rifaat is CEO of Vatica Health, a company providing risk adjustment and clinical quality improvement services to health systems and medical practices.