McFarland Clinic (McFarland) joined Caravan’s Stratum Med ACO as founding members in 2019. Comprised of 65 Adult Med and Family Med PCP's, McFarland serves a rural community in Ames, Iowa. When they transitioned to value-based care the McFarland staff worked closely with their Caravan team to place more emphasis on HCC coding in order to use data to recognize opportunities and gaps in care.

Rural communities face challenges that urban communities either don’t experience or are more immune to due to more resources. For example, the health disparities of rural communities include lower life expectancies, higher incidences of health risk factors, limited access to health care specialists and higher rates of chronic disease. According to the Rural Health Research Gateway, the prevalence of diabetes in rural communities is 17% higher than urban areas with studies showing that rural adults more likely to be diagnosed with diabetes than urban adults. One key to chronic disease detection is the ability for health care providers to properly identify the risk factors and potential concerns in their patients.

As McFarland Clinic transitioned to value-based care methodologies, they hired Lisa Nelson, a CMA who trained to become an AAPC Certified Risk Adjustment Coder. Lisa's prospective chart review and prep gives McFarland’s providers the confidence that the ICD-10 codes are not only accurate, but also an understanding of the codes that are most important to refresh. With a Risk Adjustment Coder on staff, patient charts accurately reflect known conditions which improves care coordination between the clinic, hospital, and external facilities. Having a more accurate risk score for their population helped increase their benchmarks which lead to more shared savings opportunities. McFarland consistently sees increases in their population HCC risk scores across both Original Medicare and Medicare Advantage and for the past two years, has led all Caravan Health clients with their HCC recapture rates.

In 2020, 88% of McFarland’s patients were coded with one or more of the following identifying factors: CHF, Specified Heart Arrhythmias, COPD, Vascular Disease and Diabetes with or without complications. McFarland has successfully used HCC coding to not only improve the accuracy of their coding but to identify risk factors and take a more proactive approach to patient care. 

McFarland’s Successful HCC Process Leads Caravan Health Clients
1. Employ a AAPC Certified Risk-Adjustment Coder in population health.
2. Provide a daily list of patients with upcoming PCP visits for coder to review.
3. The patient list is prioritized by highest outstanding HCC value including both known HCC's in Epic and HCC's found in Medicare claims history but not in Epic.
4. Coder edits the problem list where appropriate and flags HCC's for provider review and documentation during the visit.
5. HCC's are auto-flagged for providers by Epic when due for refresh based on past billing or problem list.
6. Coder selects a number of past visits to audit every day to check for adequate documentation and periodically provides results to the provider documentation/coding education team.
“Our focus on HCC coding and recapture has led to an increase in identifying risk factors in patients. Diabetes can sometimes be subtle or without symptoms and therefore difficult for patients and providers to recognize. Our preventive measures and holistic patient approach, including reviewing diagnoses made by providers external to our organization, is helping address risk factors earlier and intervening sooner when necessary.”
Austin Lepper
Director of Population Health
McFarland Clinic
Learn more about American Diabetes Association Alert Day and contact Caravan Health for information on accountable care and how to use value-based care to improve patient outcomes and generate new revenue.

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