You don’t have to be a certified CPC coder to do risk adjustment work. That’s probably preferred because they want to know that you’re familiar. It’s a detailed work, but you can get the CRC without being a CPC. I would suggest that somebody get the CPC and then go in and get the CRC. Unless you have a lot of experience with risk adjustment and HCC work, then just go get your CRC. And there are a lot of people out there that have been working in this field for a long time that aren’t CPCs or have other certifications and you could just go take the CRC.
A: The CPC coder deals with CPT and procedure codes whereas a Certified Risk Adjustment Coder (CRC) does not assign CPT codes. This is not to say that you don’t need to understand procedures because you do need to understand procedures. They look at procedures for a different reason than somebody that is working in physician or inpatient work.
Let’s talk about the CPC first. You assign ICD and CPT codes. You read documentation to assign codes case by case. You’re familiar with various payer requirements for optimal reimbursement. They’re corky – you know, what Medicare wants and what Blue Cross Blue Shield wants isn’t necessarily what USC (Insurance company) wants.
Understand the statistical importance of proper reporting. Don’t forget that the reason we code is primarily for statistical purposes, it just happens to be a really great way to get paid. Of course, since money is involved, the payment in reimbursement is usually what’s talked about the most.
Codes individual cases for multiple patients for each date of service – in other words, if you’re coding for all the things that came in on a Thursday and you’re coding all of that out on Friday,
you’re coding several different patients that the doctor’s office saw a hundred patients between doctors and you’re coding all of those.
It’s different for the CRC. What the CRC does is they assign ICD codes for chronic conditions which impact HCC category assignments. They read multiple forms of documentation for an individual patient encompassing a year of treatment by all approved face-to-face providers;
In other words, a CPC you may see code for a hundred patients in a day but a CRC if they’re working for an MA plan would code five patients with a year’s worth of documentation for each one and not just for one provider, for everybody that they saw in that year time period. It could be consultations, it could be specialists, it could be inpatient work. It could be all of this information and not just the one doctor that you’re used to coding for. That’s a little bit different.
HCC Requirements – Get the CRC Without Being a CPC? – Video
You have to be familiar with various risk adjustment requirements for optimal reimbursement, specific to Medicare Advantage (MA) plans, certain Medicaid plans, Affordable Care Act (ACA), Marketplace plans are all involved in this. Again, it’s a lot of work with government, and wherever government is involved, there’s usually less money; and so, the auditors are very particular because you don’t want to make a mistake, they’ll come in and take that money.
Understand the statistical importance of proper reporting and codes all encounters from a specific time period (anywhere from a quarter to a year or more) for a single patient.
Real quick, the skills of a CRC have a different focus than a CPC. They’re a little bit the same and a little bit different. One does not have to be a CPC to be a CRC; however, having a CPC would give an individual the advantage of already proven skills (very important) that just simply needs to be developed for this specialty.
Areas of further development/refinement would include: Chronic conditions – advanced knowledge in Anatomy & Physiology of the disease process, active treatments for diseases, hierarchal condition category (HCC) classifications and trumping.
Payment methodologies, you got to know about MA plans, Medicaid Chronic Illness and Disability Payment System (CDPS) and the ACA Marketplace plans, and Carrier guidelines.
Auditing – there’s RADV audit process. This is retrospective and prospective auditing. As a coder, you have to embrace auditing and being audited. As a CRC know that you’re usually 98% accuracy, is what they’re looking for. They’re looking for quality versus quantity in this area, you have to have both.
Educate – Identify documentation insufficiencies. Communication skills – communicate documentation insufficiencies as well as carrier requirements. This is so stinkin’ fun! I’m telling you guys, it’s a lot of fun!
Laureen: There was a question in the chat: Is HCC coding just for insurance companies or can an outpatient office code HCCs as well?
Alicia: Honestly,what you need to know is that there are so many avenues for risk adjustment HCC coder. You have MA plans that do the coding so that is usually you’ll see another company contract, a company to code for them, and we’re talking about massive numbers, like, thousands and thousands and thousands of people, encounters, individuals, that are coming through to be coded.
Now, for a physician’s office or outpatient facility and stuff and inpatient, you will find that they are prepping, making sure that all of their ducks are in a row before the stuff is given to the MA plans because what happens is that when it goes to the MA plan and does the coding, like, what I did with Optum is that anything that isn’t copacetic or has any error or omission on it, it’s bounced back and there’s a delay and the delay is money.
If everything is prepped and ready to go ahead of time and you’re really looking for these disease processes, the CRCs are skilled at making sure the documentation is what it needs to be to show that these chronic conditions are captured at the highest specificity – that’s a problem – with links just so that they’re currently and actively begin treated.
Again, you’re going to see CRC coders in every avenue. I know that hospitals in St. Louis are hiring and have next to their coding department; they have literally a risk adjustment HCC department that they’re adding that will have five, six to ten coders just doing risk adjustment so that they’re ready. I hope that answered your question. A little shoutout to our new project manager Chandra because she helped me fine tune this to go along with all of this great stuff, that meaty stuff I told you about that’s being added to the course.
Last thing I wanted to say before I turn it over to Laureen and her slides is that a huge part of what a CRC will do is anatomy and physiology of the disease process. If you like that aspect, which as you know I do, this is definitely a certification in career niche that you might want to get into because that is critical to stay on top of diseases and what happens in the disease process to really get to high specificities and be a good CRC.
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