Risk Adjustment: Importance of HCC Gap Closures

As a provider, you play an important role in managing care for your patients. Documenting and reporting patient complexity paints a picture of the patient’s overall health (i.e., disease burden capture). Accurate reporting is critical to support Highmark’s most vulnerable members.

As a reminder, providers should report and document all chronic conditions annually and, if possible, earlier in the year for each of their patients to promote quality of care and appropriate resource allocation. Each year, chronic conditions must be re-documented for the Centers for Medicare and Medicaid Services (CMS) because the disease burden information for all patients is reset at the start of the calendar year. Although conditions are chronic, they require annual evaluation and documentation.

To ensure compliant and accurate disease burden capture, consider these tips and best practices:

• Schedule annual wellness visits early in the year to ensure the member is seen in a timely manner. The additional time frequently provided for these appointments allows for a more thorough and accurate assessment of disease burden.
• To ensure comprehensive documentation, we recommend reviewing and submitting claims for all chronic conditions during the patient's first visit of the year, as future visits may not occur.
  • Even if the primary reason for a visit is an acute problem, consider also addressing chronic conditions if your schedule allows, especially given the potential for acute issues (like a URI) to negatively impact a chronic condition (such as COPD).
  • If addressing chronic conditions requires multiple visits, schedule follow-up appointments as early in the year as possible.
  • Utilize pre-visit evaluation and pre-charting resources through Advanced Practice Clinicians to assist with the evaluation and documentation of chronic conditions.

Proactive annual disease burden capture offers mutual benefits for patients and providers. By documenting conditions earlier in the year, we achieve:

• More timely interventions, improved care coordination across multiple providers, and access to disease management programs that can mitigate disease progression.
• Lower need for a concentrated effort on disease burden capture appointments at year-end, freeing up capacity for other essential patient care activities.

The documentation within the patient's chart is critical as it directly informs CMS and their health plan about the necessary healthcare resources required to support the patient's well-being.