Code Recapture vs New Disease Discovery

Risk adjustment code recapture analyzes ICD codes used in the prior year and presents them to the user for reconfirmation in the current year. If your risk adjustment software relies predominantly on recapture, then simply stated, your organization is “bringing a knife to a gunfight”. Recapture is an important tool and risk adjustment software should always include that functionality, but not exclusively.

As each new calendar year unfolds risk adjustment rules require that diseases, and their corresponding ICD codes from the prior year, be documented in the current year when clinically appropriate. It may seem obvious that providers would always look back at the disease burden of a patient, update their encounter notes, and redocument clinically valid diagnoses. But remember, providers don’t always see patients in the context of a calendar year. In fact, many providers see the calendar year as just an arbitrary time frame along the continuum of care. A rational provider may ask, if my patient was seen on December 31st and had all of their diseases documented, why would I perform the same work again just a month later? 

Since calendar year evaluation periods may not be consistent with standard medical decision-making processes, recapture does not always happen. In fact, our statistics, even for many well performing medical groups (gauged by RAF score), demonstrate that not every valid recapture opportunity is documented during the measurement year.

If your organization is interested in using risk adjustment software, it’s not hard to find rudimentary HCC coding recapture tools. Any EHR vendor can build software that just recaptures codes. The low hanging fruit is always the easiest to pick, but relying on recapture alone, for a population of patients, often results in missed RAF score opportunities and under-documentation. 

Recapture and New Patients

Most new patients don’t arrive for their first encounter with a perfectly coded list of ICD codes from the prior year. Oftentimes, they bring a stack of printed records, which the medical group staff simply does not have the resources to sort through. Remember, seniors generate several visits per year and with EHR “note bloat” the burden of assimilating old records into a new chart is overwhelming. For new patients, recapture is usually not a realistic strategy.

Recapture and Disease Progression

Even with the best care, the natural evolution of many chronic diseases is to worsen. Diabetes is a good example. If in the prior year, diabetes without complication was coded, it is possible that in the current year the patient has progressed, and may have a complication of diabetes such as nephropathy, neuropathy or retinopathy. For patients with progressive diseases, recapture alone simply doesn’t work.

Disease Discovery

Disease discovery uses the structured clinical data already in your EHR system (medication and problem lists, lab test results and vital signs) plus the data buried in the unstructured data (text and PDF clinical notes) to make it easier for software to understand clinical records. ForeSee Medical has a powerful artificial intelligence engine with NLP technology (natural language processing) that leverages machine learning in healthcare to help mine text and PDF notes for the 80% of the data not included in structured data sets. The information is extracted and compared from both structured and unstructured formats with a complex set of proprietary medical algorithms to discover diseases that recapture alone simply never will.

Suspect Opportunity Comparison

We studied a well performing organization that had RAF scores significantly above the national average, who are also users of our ForeSee ESP software platform. We examined the number of recapture suspects displayed in our software, but only after the patient population completed several encounters in the current year. We compared that with the number of new disease suspects discovered by ForeSee ESP, for the same population, after the same number of encounters. The number of new disease suspects from new HCC categories dwarfed the recapture suspects by around a 4:1 ratio. The amount of RAF score lift opportunities was significant, proving that without ForeSee ESP software, under-documentation would have occurred, and the amount of resources in dollars would not have been appropriate for the disease burden of the patient population.

We all want to document the disease burden of our patient populations accurately. Medical note bloat within EHRs and complex coding models make that job challenging for coders and physicians. When basic word processing software included spell-check, it began to offer the assistance needed to make writing a simple letter or email more accurate. Now, with new computing power that leverages AI in healthcare such as NLP technology and medicine machine learning, it’s time to use software to assist in doing what recapture alone will never do – accurately discover disease.

You work hard to offer medical services to complex populations, and with the rise of value-based care reimbursement models, disease discovery is keyed to high quality care and consequently, sustainable profitability. See how AI powered software from ForeSee Medical can help you perfect your risk adjustment scoring and get you the reimbursements you deserve.

Blog by: The ForeSee Medical Team