Success Codes—Patient Condition Counts, The Sun Tzu Edition

Last week, we distilled down CMS’s most recent 60-page proposal to revise the risk-coding system down to a couple of paragraphs.



Today we look at how to take that information and get ahead of the curve?



The first step is to back to your Sun Tzu in The Art of War—“They who try to control everything, controls nothing.”




A given patient will be awarded a higher RAF score if they are found to have diagnostic risk-codes submitted that cover 5 or more HCC groups.  These additional “risk-factors” will be created out of thin air, there will be no concomitant increase in the overall dollars of Medicare Advantage funding. The change is meant to “fine-tune” the risk-coding system to more closely align with costs.




Extra risk-codes. No extra money.





This will lead to an inflation effect—there will be less financial return on each piece of data you identify and submit.




Some may respond by redoubling their efforts to collect every code in sight.




That would be a mistake.




As a PCP or an organization, you’re going to have to target your efforts.




Your overall strategy for success, explained in depth throughout this blog, still stands:


Create systems that ensure you:

  • Grow Your Panel
  • Get Them In Once a Year
  • Take Great Care of Them




With the proposed revision to the risk score system, here are some tweaks:


  • Don’t spend too much time harvesting risk-codes in the hopes of getting a higher RAF score, let it happen organically. The additional Patient Condition Count (PCC) “bonus” doesn’t kick in until a patient has had codes submitted that represent a minimum of 4-5 total HCC groups—even then the adjustment is very modest until you get to 8 or 9. It’s really not really worth the time spent hunting for that last risk code to put you into the next category. Consider the PCC adjustment a passive “bonus,” one that allows you even more financial leeway to care for your seriously ill patients.



  • If you find yourself compelled to harvest risk-codes in the hopes of getting the PCC “bonus,” concentrate on doing so for your > 65-year-old “dual-eligibles” (on both Medicare and Medicaid) patients.  They will, by far, give you the most bang for your buck.



  • Although all the diagnostic risk codes for institutionalized patients have value, those for morbid obesity and hematologic abnormalities outsized value compared to the rest. Don’t order CBCs just to find the codes, but when you have to order the tests, review them with these codes in mind.



Expect a continuation of the megatrend of continued “data devaluation” by CMS in the name of “optimizing” the risk-coding system.



If your goal is to generate the greatest amount of value in the fixed amount of hours you want to devote to your Medicare Advantage contract, a systematic approach is now more important than ever.



Like Sun Tzu says:  “Pick your battles and win your war!”



I can only add:  “…and you’ll have time enough to enjoy your success.”