Value-Based Care in Medical Specialties: Improving Hierarchical Condition Category Capture

Risk adjustment plays a key role in payment, especially in value-based payment models, which use a practice's performance with cost and quality metrics to determine reimbursement. Inaccurate representation of a patient's medical complexity can cause a practice to fall below cost and/or quality performance targets, potentially leading to a substantial loss of shared savings dollars. This quality improvement study evaluated the effectiveness of a clinical documentation excellence program, focused on addressing hierarchical condition category diagnoses, involving the medical specialties. The program included tools in the electronic health record, metrics to monitor and provide feedback on clinician performance, and regular interactions with the nurse and physician leads for each specialty. For clinicians of medical specialties, the education program resulted in an increase in the percentage of hierarchical condition category diagnoses addressed at outpatient encounters from 25% to 62% over a 2-year period.