Understanding Prospective, Concurrent, and Retrospective Reviews

By Jayashree Selvaraj

January 18, 2024

HCC Coding Review Types

The CMS-Hierarchical Condition Category (HCC) model is a prospective risk adjustment model implemented to estimate the future expenditures of Medicare beneficiaries. Initially, it was employed by the Centers for Medicare and Medicaid Services (CMS) to adjust capitated payments to Medicare Advantage plans but is now used to calculate payments for Accountable Care Organizations and Affordable Care Act Marketplace. HCC coding reviews are essential for financial success in value-based contracts.

here are three common types of HCC coding reviews:

  • Prospective Review
  • Concurrent Review
  • Retrospective Review

Prospective Review

Prospective coding review is a process intended to help physicians prepare for upcoming patient encounters. Certified coders with clinical knowledge review the patient’s condition history, medications, hospital records, lab results, and physician notes. They identify patients with likely HCC conditions whose diagnosis codes have not been captured accurately and prepare the provider for the patient appointment. This communication is often performed via updates to the electronic health record (EHR) problem list or delivered to the physician ahead of the patient’s visit via a report. The physician must then ensure that the noted conditions are documented and included in the encounter as appropriate.

This type of review ensures that providers are aware of all conditions and quality gaps that may have not been documented and coded, reducing the administrative burden on the physician at the time of patient’s visit.

Concurrent Review

Concurrent review is a process where HCC coders analyze the patient's chart, clinical notes, and HCC codes prior to submitting claims to the payers. Although it is similar to a real-time review, there is some lag involved. This process requires the coders to have remote access to review the diagnosis codes before claim submission. It helps ensure that the diagnosis coding accurately supports what the physician documented in the electronic medical record (EMR).

Concurrent coding review ensures that the providers’ hard work in delivering care and documentation is translated into accurate HCC codes onto the claim. Payers receive the correct codes on the initial claim, which eliminates the need for additional retrospective review. Concurrent review works best in tandem with other initiatives such as prospective review or retrospective review and provider and office staff coding education.

Retrospective Review

Retrospective coding review is done after care has been provided and claims have been submitted to the payer. This process is most often used by Medicare Advantage plans. The goal is to carry out a post-audit and potentially uncover unreported HCC codes and wrongly reported HCC codes. Wrongly reported HCC codes include codes that should not have been submitted because they did not meet documentation guidelines and codes that are not reported to the maximum specificity/severity.

Review Best Practices

Using a combination of reviews may seem overwhelming at first glance, but it’s the smoothest and most cost-effective way to yield the greatest operational and financial benefits. Combined prospective and concurrent review ensures accurate documentation and claims. Proper implementation of prospective reviews significantly increase the likelihood that the physicians will get the documentation right the first time, which decreases back and forth communications, corrections, and overheads during the concurrent stage. Additionally, detailed concurrent review can reduce or eliminate the need for retrospective reviews.

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Jayashree Selvaraj


Jayashree Selvaraj is the manager of the medical coding and CDI services for AGS Health. In this role, she contributes to the development of medical coding and CDI service line strategy and execution. She has more than a decade of experience in medical coding and training and development. Jayashree holds a bachelor’s degree in biotechnology from Anna University, India. She is also a Certified Professional Coder (CPC) and Certified Risk Adjustment Coder (CRC) from the American Academy of Professional Coders (AAPC).

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