Patient Risk Adjustment (HCC/RAF): Diagnosis Gaps Report

Display the Report Library: On the Main Menu, click Reports. Under General, click Report Library. Click the Clinicals tab. In the Standard Reports section of the tab, click run next to Patient Risk Adjustment (HCC/RAF): Diagnosis Gaps Report.

To access reports on the Clinicals tab of the Report Library, you must have the Clinicals user permission and the Report: Report Library: Clinicals permission. The Report: Report Library: Clinicals permission is included in the following roles:

• Practice Superuser role
• Report Reader role

Note: To activate the Patient Risk Adjustment (HCC/RAF): Diagnosis Gaps report, use the Activate Reports page.

athenahealth recommends that you run the Patient Risk Adjustment (HCC/RAF): Diagnosis Gaps report on a weekly basis for patients with appointments scheduled in the upcoming week. Organizations with care managers or other staff focused on risk adjustment may want to automate the delivery of this report to those staff members each week, whereas other organizations may want to send the report directly to providers.

1. Display the Report Library: On the Main Menu, click Reports. Under General, click Report Library.
2. Click the Clinicals tab.
3. Click run next to Patient Risk Adjustment (HCC/RAF): Diagnosis Gaps Report in the Standard Reports section of the tab.
   The Run Report: Patient Risk Adjustment (HCC/RAF): Diagnosis Gaps Report page appears.
4. Next Appointment Day — Enter the start and end dates for the report, or select a date range from the menu (for example, Next 7 Days). Patients who have appointments scheduled during this date range appear in the report.
5. Include patients without appointments — By default, only patients with scheduled appointments are included in the report, but you can also report on patients who do not have appointments scheduled during the selected date range.
6. Department — To report on patients who have appointments scheduled in specific departments only, click Selected and then select the departments to include in the report.
7. Provider — To report on patients who have appointments scheduled with specific providers only, click Selected and then select the providers to include in the report.
8. Insurance Product Type — To report on patients who are insured by specific insurance product types only, click Selected and then select the insurance product types to include in the report (for example, Medicare B-Traditional or Medicare Supplemental Plan).
9. HCC Description — To report on patients with specific chronic conditions only, click Selected and then select the HCC descriptions of the chronic conditions to include in the report.
10. Insurance Reporting Category — To report on patients whose insurance plans fall under specific insurance reporting categories only, click Selected and then select the insurance reporting categories to include in the report (for example, AARP or Medicare B).
11. Report Format — Select the format for your report results.
• HTML table — Display the report results on your screen.
• Text (tab-delimited) — Export the report results to a .csv file in tab-delimited format.
• Text (comma-delimited) — Export the report results to a .csv file in comma-delimited format.
12. Report Options — Select report options.
• Suppress Column Headings — Select this option to remove column headings from the report results.
• Suppress Report Name — Select this option to remove the report name from the report results.
• Show Filter Criteria — Select this option to include your selected filter criteria in the report results.
• Run Offline (will appear in your Report Inbox tomorrow morning) — Select this option for very long reports. Reports that are run offline appear in your Report Inbox the morning after the request.
13. Click Run Report.

The Hierarchical Condition Category (HCC) model assigns a risk adjustment factor (RAF) to chronic conditions common in Medicare patients. The combination and number of patient diagnoses is then translated to a total RAF, which insurance companies use to determine the annual payment for the patient. You can view HCC RAF information during the point-of-care workflow, including diagnosis-level RAF weights and patient RAF scores, and using the HCC RAF GAP report.

Note: HCC diagnoses must be captured each 12-month calendar year to count toward risk adjustment for that year. All athenahealth HCC features reset on January 1 of each year because a patient's risk score is calculated over the course of a calendar year.

For more information, see Patient Risk Adjustment and the Patient Risk Dashboard.

Patient Risk Adjustment (HCC/RAF): Diagnosis Gaps report

 

The Patient Risk Adjustment (HCC/RAF): Diagnosis Gaps report identifies patients for whom a diagnosis associated with an HCC was coded on a claim or in a clinical order in the past 3 calendar years but has not been submitted on a claim in the current calendar year. This report is intended for use by clinical staff who can directly affect the rediagnosis of a patient during a clinical encounter.

• You can run this report by appointment date to identify the patients that you are seeing in the near future who have chronic conditions associated with HCCs.
• You can filter the report by department, provider, insurance product type, insurance reporting category, and hierarchical condition category.

Tip: To make the number of patients in the report manageable, you can limit the gaps report to diagnoses not included in the HCC Risk Adjustment QM program.

 

athenahealth recommends that you run the Patient Risk Adjustment (HCC/RAF): Diagnosis Gaps report on a weekly basis for patients with appointments scheduled in the upcoming week. Organizations with care managers or other staff focused on risk adjustment may want to automate the delivery of this report to those staff members each week, whereas other organizations may want to send the report directly to providers.

 

HCCs excluded from the report

 

The following HCCs are excluded from the Patient Risk Adjustment (HCC/RAF): Diagnosis Gaps report because the diagnoses are for acute conditions.

CMS HCC Model Category	HCC Description
2	Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock
83	Respiratory Arrest
135	Acute Renal Failure
162	Severe Skin Burn or Condition
166	Severe Head Injury
169	Vertebral Fractures without Spinal Cord Injury
170	Hip Fracture/Dislocation