HCC Coding and Risk Analysis

Automated HCC Code Identification

AI-Powered Code Extraction: More than 90% of ICD code selection and HCC grouping is automated, drastically reducing coder workload and variability, while maintaining human-level accuracy.

Predictive Intelligence: Proactively identify undiagnosed conditions by analyzing lab, Rx, and claims data to close care gaps and capture prospective HCCs.

Advanced Configurable Rules Engine: Identifies potential HCC codes by evaluating clinical documentation against coding guidelines, payer-specific rules, and risk adjustment models.

Full Model Support & Customization: Supports CMS-HCC V24/V28, HHS-ACA HCC, ESRD, and RxHCC models. Configure criteria by plan, line of business, or risk adjustment programs based on state regulations.

Seamless Data Intake & Extraction

Broad Intake Channels: Supports diverse data sources including EHR data feeds, claims data, secure provider portals, fax-to-digital ingestion, and APIs with real-time processing.

Intelligent Clinical Data Extraction: HCC focused AI Language Models parse structured and unstructured data from physician notes, discharge summaries, lab results, and clinical documents.

MEAT & Evidence Validation: MEAT (Monitor, Evaluate, Assess, Treat) evidence validation dynamically captured from unstructured EHR notes with customizable logic for different provider types and payers, including pre-extraction checks.

Longitudinal Data Integrity: Tracks member history to flag suspected missed diagnoses and suggest the deletion of non-relevant codes, ensuring record accuracy.

Automated Risk Score Calculation 

Integrated RAF Score Calculator: Instantly calculate risk scores using the latest CMS & HHS models with all relevant demographic and plan factors.

Built-in Trumping Logic Engine: Automatically resolves diagnosis hierarchies to capture the highest-value HCC and eliminate coding errors. 

Confidence-Based Code Approval: Auto-approve high-confidence codes while flagging others for manual review to optimize coder productivity.

Seamless Core Integration: Connect with your core claims, enrollment, and risk systems via robust APIs for real-time data consistency.

Comprehensive Compliance & Tracking

V28 Transition Automation: Automatically applies the blended V24/V28 (33% / 67% blending) models to ensure calculation accuracy & compliance during the CMS phase-in.

Provider Specialty Validation: AI confirms the rendering provider is authorized and the specialty is clinically appropriate for the diagnosis, reducing downstream denials and audit risk.

Productivity-Driven Workflow: Boosts team efficiency with intelligent routing of cases to designated staff and customizable alerts for documentation gaps or pending reviews.