The Power of Pre-Visits in Maximizing Patient Care and Profits

Over the years, we have witnessed the healthcare system shifting to an incentive structure where physicians are rewarded for better care rather than just more care. This move from a Fee-for-Service model to Value-Based Care is transforming how physicians document their work, get paid, and improve patient outcomes—and it's also reshaping our business practices. As a result, we need to rethink our approach to medical coding; sticking to old methods just won't cut it anymore. 

Value-Based Models (VBM) come in various forms, such as MIPS and MACRA plans, population health incentive programs, and risk adjustment in Medicare Advantage, Medicaid, Accountable Care Organizations, and commercial plans. In all these models, the measures and/or conditions being monitored are to account for the ‘expected costs’ of specific patient populations. Essentially, if a patient is sicker, more funding can be allocated for their care. The goal of Risk Adjustment coding and reviews is to accurately capture and quantify the level of illness or medical complexity, ensuring fair distribution of funds, aligning incentives with rewards, and enhancing the overall quality and efficiency of patient care. 

Based on a case study AAPC Services performed in 2022, most practices were over- and under-coding HCC ICD-10 codes due to insufficient documentation, coding errors, and high utilization of unspecified codes. As a result, there was a loss in shared revenue of $160,000 annually. 

We know the best solution to ensure quality patient care, accurate coding, and financial success is to incorporate medical record chart reviews. But what kind of reviews are best? How often should these reviews be done? And how do you find the time to do it?  

I am a firm believer in “doing things right the first time,” as it’s far better than fixing it later. This is where pre-visit reviews come in. A pre-visit review is intended to help physicians prepare for upcoming patient encounters. These reviews are often performed by clinical staff, as well as certified risk coders (CRCs). Performing this review prior to seeing the patient is like baking chocolate chip cookies. You have to first make sure you have all the necessary ingredients including the chocolate chips, otherwise, you will never get the amazing cookies you desire.  

Clinical Benefits of Pre-visit Reviews 

Pre-visit reviews enable healthcare teams to coordinate services and allocate resources more efficiently for patients with complex or chronic conditions. By reviewing the patient’s medical records in advance, the multidisciplinary care team can identify individual patient needs, determine if specialists or allied health professionals need to be involved in the visit, arrange for specialized equipment or supplies, and ensure the availability of support staff such as interpreters, ‘strong man’, or other caregivers. 

Pre-visit reviews serve as a proactive means to identify potential health risks and issues ahead of the patient’s appointment. Clinicians analyze the patient’s medical history, laboratory results, and other relevant data, to identify risk factors, such as suspected chronic conditions, adherence to treatment plans, medication interactions, or abnormal test results that need to be followed-up on. This proactive approach not only optimizes the visit process, but also reduces wait times, lightens the physician’s workload, and enhances patient care. 

Financial Benefits of Pre-visit Reviews 

Employing CRCs to support the pre-visit review process is essential to ensure accurate payment. A skilled coder can identify potential coding errors as well as documentation inconsistencies and gaps that can be resolved before the patient’s upcoming visit. Proactively identifying coding gaps in advance helps to maximize the reimbursement by avoiding both under-coding, where the assigned codes do not fully reflect the complexity or severity of the patient's condition, and over-coding, which overstates the level of specificity resulting in a higher RAF score. For instance, a commonly assigned ICD 10 CM code of F32.A for “Depression, Unspecified” is often reported; however, the documentation is suggestive of a more specific code such as F32.0-F32.5 for ‘Major Depressive Disorder, Single Episode, with a status.’ Unlike F32.A, these specific codes risk adjust, presenting a missed opportunity for capturing accurate reimbursement. Addressing such documentation gaps empowers coders to ensure precise coding that aligns with the claim. 

Furthermore, coders can guide physicians toward compliant documentation practices, to ensure coding practices align with current coding guidelines which will reduce claim denials and lower penalties from CMS Risk Adjustment Data Validation (RADV) and other payer audits. By aligning coding practices with current guidelines, coders safeguard against potential revenue loss and strengthen financial integrity. 

Process for Pre-Visit Reviews  

Before implementing the process of pre-visit reviews, it is essential to first know your target. This reminds me of Stephen R. Covey’s quote from the 7 Habits of Highly Effective People, “Start with the end in mind”. Knowing your destination will help you gain a better understanding of where you are today and what steps you need to take to get to where you want to go.  

The objective of a Risk Coder Pre-visit review is multifaceted. The goal is to identify patients with likely or suspected HCC conditions, pinpoint diagnoses that may not have been accurately captured, uncover documentation conflicts or incomplete notes, identify missing status updates of conditions, and rectify coding errors. Achieving this goal requires a thorough review of the patient's medical history and previous visits to their primary care provider and specialists. Typically, a review spanning 12 to 18 months is optimal. Anything less may result in missed HCC opportunities.  

If a comprehensive review of the entire record within the designated time frame isn't feasible due to resource constraints, prioritization becomes imperative. Focusing on specific providers treating conditions associated with the specific risk adjustment model and targeting particular visit types, such as annual check-ups, can result in quick wins. 

Once the scope is determined, begin by pulling each physician’s patient schedule one to two weeks before the appointment. Some organizations prefer the coder review to take place two to five days in advance. It’s essential to strike a balance: pulling schedules too far in advance is likely to result in overlooking last-minute appointments. Whatever your threshold is, keep in mind that anything beyond 30 days is too far out. A lot can change with a patient in 30 days.  

Because coders are not clinicians, they often feel uncomfortable reviewing diagnostic tests for missed coding opportunities. Providing clear directives and comprehensive training empowers coders to effectively utilize their skills in interpreting medical records so that suspected conditions can be identified for the physician to then accept or decline.  

Coders must spend their time wisely. Beginning the review process with the problem and medication lists offers a holistic view of chronic conditions requiring attention during the upcoming visit. Next, analyze diagnostic tests and laboratory results for changes or indications of new conditions to be added to the problem list. Followed by a review of specific visit notes. Consultation notes are excellent to review as they often unveil new conditions diagnosed specialist. 

Closing the Loop Through Physician Queries  

Clear and concise communication of the coder’s findings regarding suspected HCC conditions, coding errors, and documentation gaps is critical. This communication must be conducted efficiently, ensuring minimal disruption to physicians. Utilizing tools such as EHR messaging queues, alert notices, or integrating physician queries into the order workflow can facilitate seamless communication. Regardless of the method(s) used, physician queries must be precise in why and what needs to be clarified, include only the facts, and must be compliant with the organization’s guidelines. The coder should refrain from leading the physician or discussing the impact on reimbursement.  

Moreover, fostering collaboration between coders and physicians can enhance the effectiveness of communication. Coders may benefit from participating in clinical huddle meetings, facilitating real-time discussions and clarifications.   

Physician Responsibility 

Physicians have a key responsibility in the pre-visit review process. It’s imperative that they actively contribute to the development of the process, participating in clinical huddles, and review coder queries prior to seeing the patient. Additionally, physicians bear the responsibility of addressing all patient conditions, resolving documentation gaps, and completing visit notes in a timely manner.  

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Overcoming Challenges 

With any process in healthcare, there are always challenges. Pre-visit reviews are no exception. The biggest challenge is having the staff with the correct skill set perform these reviews. Time is another challenge, followed by a lack of technology to assist in streamlining the process. And finally, lack of ‘buy in’ from within the organization. 

To address these challenges, it’s essential to enlist the support of key stakeholders such as your CFO, compliance manager, practice manager, and physician champion. Investing in training your coders and in technology can significantly mitigate obstacles by automating various steps in the process. Consider leveraging HCC analytic tools to identify suspected conditions, implementing computer-assisted coding (CAC), or integrating artificial intelligence (AI) coding tools. Customizing EMR workflows to incorporate alerts and messages are also effective solutions. Demonstrating the financial benefits of these investments is crucial. Presenting industry case studies highlighting the risks associated with incorrect coding can increase support.

Additionally, conducting a proof of concept by piloting the process with a small group of providers for thirty days, followed by a formal return on investment summary, can provide tangible evidence of the potential gains. Implementing a thorough pre-visit review process not only lightens the physician's workload, but also enhances medical record documentation.

Furthermore, pre-visit reviews streamline processes, mitigate denials and compliance risks, ensure coding precision for optimized reimbursement, and empower physicians and clinical teams to deliver quality care to patients. By embracing pre-visit reviews, healthcare organizations can navigate the complexities of HCC risk adjustment with confidence, ensuring both financial viability and patient well-being. 

How Can AAPC Help? 

AAPC offers a range of services designed to support healthcare organizations optimize coding processes, improve documentation accuracy, and maximize reimbursement opportunities — while maintaining compliance with current coding guidelines and regulations. Among these services are: 

• Risk Adjustment Coding: AAPC's expert coders can ensure your organization accurately captures the level of illness or medical complexity for individual patients or groups.  
   

• Customized Training: Whether it's training on the latest coding guidelines or specialized guidance for your coders and clinical staff, AAPC’s provides tailored training to help you stay compliant and proficient in your coding practices. 
   

• CRC Certification: The Certified Risk Adjustment Coder (CRC) credential signifies expertise in risk adjustment coding and documentation, ensuring your staff are equipped to handle its complexities. 
   

• Codify by AAPC: Codify streamlines the coding process, supporting coders in capturing the right codes and avoiding errors that could impact reimbursement. 

 References: 

• https://www.aapc.com/blog/84804-converting-risk-into-revenue/ 

• https://www.aapc.com/resources/the-power-and-profitability-of-risk-adjustment-reviews