Accurate Documentation and Diagnostic Coding

The Accurate Documentation and Diagnostic Coding (ADDC) team ensures that all key stakeholders are aligned and are working in a unified manner to enhance capture of the high-quality patient care we provide. The ADDC team collaborates with ambulatory providers to identify and communicate best practices and opportunities regarding documentation guidelines and coding requirements. The team’s goal is to improve the overall quality and completeness of patient medical records.

At the end of 2022, Baptist Health signed an agreement with Stanson Health to integrate the Stanson HCC Solution within the Epic workflow for Baptist Physician Enterprise physicians, for patients attributed to BPP. This solution, which is scheduled for mid-2023 implementation, provides real-time alerts for treating physicians at the point of care. Alerts identify and suggest a hierarchical condition category (HCC) codes based on existing documentation within the patient’s chart. The treating physician then has the opportunity to document the monitoring, evaluation, assessment, or treatment of the suspect condition in their progress note and add the code to the claim record; or to decline to add the code, as they deem appropriate. The goal of HCC documentation is to capture the patient’s actual clinical picture, including disease severity and associated risk, and then assign an appropriate HCC code.

Payers use HCC codes submitted to them on claims to determine applicable benchmark costs under shared savings arrangements. Accurate documentation and coding efforts are critical factors driving performance in value-based care models.