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Complete, accurate coding & auditing powered by AI

Protect your risk adjustment program performance with an integrated chart review solution that lets you look for supported net-new HCCs and confirm the accuracy of existing codes.

The growing need to look both ways

Compliance has never been more important for retrospective risk adjustment programs. With mounting pressure from the CMS, OIG, DOJ, and other regulatory bodies to crack down on overpayments and fraudulent reporting, organizations are putting their programs at increasing audit risk. But manually looking both ways—that is, reviewing charts to find missing supported HCCs and identifying coded HCCs lacking sufficient evidence—is time-consuming, costly, and unscalable.

Given these challenges, most organizations audit only a fraction of codes submitted to CMS or HHS. In Apixio’s 2018 risk adjustment coder survey, 60% of respondents indicated that their organization performs a QA review on 30% or fewer of all coded charts. This lack of oversight creates a financial and reputation liability for payers participating in government programs.

Fast facts

$ 0 Billion
in risk-adjusted payments made to MAOs in 2017 for chart review diagnoses not linked to claims services
0 %
of Medicare HCC submissions lack sufficient documentation according to CMS
3 - 0 %
of known HCCs are unsupported by documentation in charts
HCCIdentifier Coder Workflow - 2020

HCC Complete: AI-powered coding and auditing

Apixio’s HCC Complete solution uses proven AI algorithms to support a comprehensive retrospective chart review experience for Medicare Advantage and Affordable Care Act programs. Our technology identifies both missed coding opportunities and unsupported known codes and serves them up for coder review and QA in a straightforward workflow. As a result, your risk adjustment team can review more charts more efficiently, ensuring your coding submissions are as complete and accurate as possible.

HCC Identifier Project Dashboard - 2020

Benefits of looking both ways with technology

  • Improved Coding & Auditing Accuracy. AI algorithms serve up predicted evidence of supported and unsupported HCCs for review, helping reviewers accurately code member risk. Our coding application supports up to three levels of QA and an optional blind review of rejected coding opportunities flagged for coder bias to ensure your team captures the full truth. 
  • Protect Your Program from Audit Risk. AI algorithms identify condition codes on claims and supplemental submissions that may lack sufficient evidence, putting your organization at audit risk. Potentially unsupported HCCs are routed for review in an efficient auditing application to ensure providers, internal coders, and vendors are making defensible, accurate coding decisions.
  • More Effective Coding and Auditing. Instead of reading through hundreds of pages of patient charts, reviewers are pointed to specific pages with either supporting evidence of net-new HCCs missing evidence of an existing code, drastically reducing review times. Existing codes confirmed by our algorithms aren’t routed for additional review, helping your audit team focus their attention on reviewing the highest risk codes. 
  • Optimized Risk Coding & Auditing Performance. Project dashboards give you insight into your team’s coding and audit performance so you can identify any issues early and educate reviewers who may be missing the mark. We also provide robust coder management tools to help you optimize your assignments and workflows.

Program impact

0 %
reduction in coding & audit review time
0 %
increase in coding accuracy
4 - 0 X
increase in chart review productivity
Client Testimonial
Scripps logo

By using Apixio, we’re improving our auditing bandwidth and enhancing the ability of our coders to focus on other chart audits and other projects that we couldn’t do before.

JoAnn Hayden
Scripps Health Plan Services
HCC Identifier Performance Dashboard 2020

Flexible application and service options

Whether you manage risk adjustment coding and auditing in-house or outsource chart reviews to vendor coders, Apixio can support your first- and second-pass chart review programs. HCC Complete is available as both a: 

  • Web-based application (1st-pass reviews): Our robust coding application supports in-house coder teams. Managers have full control over project assignments, QA workflows, and audit workflows to maximize accuracy & efficiency. 
  • Technology-based service (1st- and 2nd-pass reviews): Our service solution combines the power of Apixio’s AI platform with seasoned coders to review charts according to your organization’s coding & compliance guidelines.
Gain a complete, accurate picture of member risk with HCC Complete