How uncoded health conditions can affect the entire healthcare ecosystem

According to the Centers of Disease Control and Prevention, more than 100 million* Americans with chronic ailments often suffer from multiple conditions. Often, these patients don’t receive a complete diagnosis, leaving their records uncoded, which may affect the patient’s future quality of care. A recent case study conducted by PRX with more than 1 million prescriptions from Medicare patients, revealed that more than 13% of the prescriptions didn’t match a diagnosis of the patient.

Which are the consequences of uncoded conditions?

1) Unaddressed patients

Uncoded health conditions may be due to a miss diagnosis or that the physician didn’t address a specific condition of the patient, by which the patient may get worse.

2) Quality of care

If the patients’ primary care physician is out of the office and the patient gets checked by a locum physician fulfilling the duties of the PCP, the latter may not be completely aware of all the patients’ conditions, therefore undertreating the patient and delaying care.

3) MACRA law: value-based care

In April 16 2015 the MACRA (Medicare Access and CHIP Reauthorization Act) legislature was signed into law, which rules would be later approved and implemented by November 2016. The most important rule on MACRA is the new payment models to physicians who care for Medicare beneficiaries. Under the MACRA physicians will be compensated on merits and the results of the patients’ outcomes. CMS will rate physicians based on the acute and chronic composite measures for ambulatory care sensitive conditions (ACSC) and total all-cause hospital readmissions.Hence, physicians need to be more careful with charting and documenting the patient.

4) Population health management

Population Health Management is the aggregation of patient data across multiple health information technology resources, the analysis of that data into a single, actionable patient record, and the actions through which care providers can improve both clinical and financial outcomes. Government agencies, payers and health systems use this data to measure the health state of a specific geographic region (county, city or state). Without proper coding these measurements may be off which can affect the data used to calculate the metrics for value-based payments.

To reduce uncoded health conditions, a company called PRX Control Solutions developed a free add-on for EHR (electronic health records) vendors that allows healthcare providers match the patients’ health conditions and medications, alerting them of uncoded chronic conditions and the prescription of a controlled substance or antibiotic without a proper diagnosis code.

About PRX Control Solutions: PRX is digital health company based in Miami, Florida that offers a smart prescription platform to health plans and payers, focused on detecting improper prescriptions, abuse and waste, and on providing better prescription data to their clients.