Integrating Clinical Documentation Improvement with HCC Coding Workflows

Everyone in the value-based care model aims for fair reimbursement, but inaccurate medical coding bleeds revenue. However, if you use CDI in HCC coding workflows, you can capture the full picture of patient conditions. This reduces billing inaccuracies and their associated penalties.

The upside? Recent data reveals that 90% of hospitals using CDI generate over $1.5 million in additional revenue per year. 

So, should you integrate it? How can aligning CDI with HCC workflows enhance your operational efficiency? Let’s find out. Before exploring this integration, let's first understand what CDI entails and why it matters.

Understanding Clinical Documentation Improvement

CDI means improving patient records so they clearly show, among other things, the person’s health condition. This helps doctors code correctly, get paid fairly, and follow regulations.

Benefits of CDI

When implemented effectively, CDI offers several measurable advantages for healthcare organizations:

• Reduced Denials: Strong CDI programs can reduce claim denials by up to 40%.
• Improved Patient Care: Get a comprehensive view of a patient's health status, so you can deliver personalized care.
• Improved Response Times: Integrated CDI programs with tech-assisted query tools reduce back-and-forth between coders and providers.
• Protects Against Audit Penalties: CDI builds defensible documentation trails, making it easier to pass audits.
  
  

Now that we understand CDI, let's examine the coding system it needs to work with—Hierarchical Condition Category (HCC) coding.

What’s HCC Coding and HHS-HCC Risk Adjustment Model

Hierarchical Condition Category (HCC) coding is the backbone of how healthcare organizations get paid fairly under risk-based models like Medicare Advantage.

It groups related diagnoses into categories based on severity and the costs to manage them.

Each HCC is mapped to an ICD-10-CM diagnosis code. When combined with a patient’s age, gender, and other demographic factors, it generates a Risk Adjustment Factor (RAF) score.

Leading hospitals use these scores to predict care costs and ensure accurate reimbursement in value-based payment models. Within the broader HCC framework, the HHS-HCC Risk Adjustment Model serves a specific purpose in the healthcare ecosystem.

What’s the HHS-HCC Risk Adjustment Model

This is what the government uses to level the playing field in the ACA (Affordable Care Act) marketplace. It makes sure insurers don’t just prioritize healthy people and overlook sick ones.

Unlike the CMS-HCC model, which mostly deals with seniors and people with certain disabilities, HHS-HCC applies to everyone—kids, adults, even newborns.

HHS-HCC is for real-time adjustments. It pulls medical and prescription drug costs to calculate how much support a patient might need, and how much insurers should get paid to cover them.

Major Challenges in Integrating CDI and HCC Coding 

One big challenge is when records are incomplete or unclear. This can cause important health issues to be missed during coding, leading to lower payments and poor care planning.

Inefficient workflows and compliance gaps add to the problem. Take the OIG audit of HumanaChoice as an example:

‍157 out of 210 enrollee-years had unsupported diagnosis codes, leading to $480,295 in net overpayments. 

If you fail to detect and prevent coding errors, you risk massive overpayments and regulatory penalties.

Another major challenge is low provider engagement. Many physicians may not understand the importance of detailed documentation for coding purposes. Without their active participation, CDI teams can’t accurately capture patient complexity. This would lead to missed diagnoses and non-compliance with federal standards. 

To avoid such issues, integrating CDI with HCC coding is essential. It helps build better workflows and continuously educates providers on documentation requirements. When these integration challenges are successfully addressed, healthcare organizations can realize substantial benefits.

Why Integrate CDI and HCC Coding

This helps capture relevant diagnoses, providing precise risk scores. Here are the major benefits of this integration:

• Improved Resource Allocation: Accurate HCC risk scoring helps you to allocate resources more effectively.
• Elevated Patient Engagement: CDI enhances patient care and streamlines admin operations by optimizing documentation practices and reducing clinicians' workload.
• Strengthened Risk Stratification: By documenting social factors like housing, income, or lack of support through Z codes, CDI programs help build a clearer risk profile.

Best Practices for Integrating CDI with HCC Coding

Create a system that helps providers to document better and coders to code smarter. Here's how you can make that happen:

1. Educate and Engage Providers

Providers may not always realize how their notes can impact coding and reimbursement. Consider holding regular workshops to highlight the importance of detailed documentation.

For example, incorporating digital learning platforms alongside traditional workshops can help increase retention rates.

2. Implement Technology Solutions

If possible, customize your EHR to prompt providers for key documentation elements, like chronic conditions, complication status, or specificity in diagnosis. This makes it easier to capture what matters for HCC coding and streamlines the documentation process.

Where customization isn’t available, consider using software that can flag missing  Z codes for issues like food scarcity or housing insecurity.

3. Establish Collaborative Workflows

No one should work in silos. Teamwork is crucial to improving documentation quality. Foster collaboration between clinicians, coders, and CDI specialists to clarify documentation gaps in real-time.

Even a weekly 15-minute huddle can improve documentation quality and reduce coding delays. Implementing these best practices often requires specialized expertise and technology support, which is where solutions like HOM come into play.

How HOM Supports CDI and HCC Coding Integration

Good documentation and accurate HCC coding are key for fair payments. Here’s how HOM helps providers make smarter decisions:

1. AI-Enabled Custom RCM Solutions

By understanding how you work today, we create a custom plan to improve your records and coding process, tailored to what works best for your team.

‍Providers using HOM’s CDI services have seen up to a 40% increase in RAF scores, with over 98% accuracy and a 24-hour turnaround for chart reviews.

Our expert coders can accurately: 

• Identify the right HCC codes
• Flag documentation gaps in real-time

They also ensure each patient visit reflects the complete risk profile for accurate reimbursements.

2. Technology Integration That Works With Your EHR

Recent research shows that large language models (LLMs) can generate summaries that match or outperform human experts in 81% of cases when adapted for specific clinical tasks.

HOM’s solutions integrate with your existing IT systems, including major EHR platforms. Our AI-assisted tools help create expert-level clinical summaries and improve documentation accuracy in real-time.

Final Note

In value-based care, getting paid fairly depends on how well your documentation reflects patient risk, and that’s where integrating CDI with HCC coding makes all the difference.

With AI-powered tools and tailored CDI programs, HOM helps you build smarter workflows that boost accuracy and support better outcomes.

Partner with HOM and start capturing the full value of care. Request a free audit today.