My colleague Beth discovered something wild last month. She was reviewing risk adjustment HCC coding accuracy when she noticed we’d missed the same $4,000 HCC on dozens of patients. Not because of poor documentation. Not because of coder error. Because nobody thought to look at the medication list.
The patient was on three different antipsychotics. That screams major depressive disorder with psychotic features. But the primary care note just said “mood issues.” We coded nothing. Four thousand dollars, gone. Multiply that by hundreds of similar cases.
The Medication Gold Mine
Your patients’ medication lists are telling you stories that progress notes ignore. Insulin means diabetes, sure. But what about memantine? That’s dementia hiding in plain sight. Digoxin? Heart failure is lurking there. Tacrolimus? Some transplant status you’re missing.
We started a simple experiment. Before reviewing encounter notes, coders check medications first. Just a quick scan. The results knocked us sideways. We found 31% more HCCs just by knowing what to look for in the documentation.
Take Mr. Rodriguez. His PCP note mentioned “kidney issues” twelve times over two years. Vague, uncodeable. But his medication list included epoetin alfa. That’s not for casual kidney problems. That’s chronic kidney disease, probably stage 4 or 5. Armed with that knowledge, our coder dug deeper and found a buried nephrology note confirming CKD stage 4. Boom, HCC captured.
The psychiatric medications are the biggest missed opportunity. Providers document “depression” when patients are on antipsychotic combinations that indicate severe mental illness. The difference between simple depression and severe depression with psychotic features? About $2,800 per year.
The Specialist Breadcrumb Trail
Here’s another pattern we miss constantly: specialists prescribe medications that tell you exactly what conditions they’re treating, but their notes end up in some electronic void.
Cardiologists prescribe spironolactone for heart failure. Endocrinologists adjust insulin regimens for diabetic complications. Pulmonologists prescribe triple therapy for severe COPD. The prescriptions make it to the medication list. The specialist notes? Good luck finding those.
Now when coders see specialist-specific medications, they know to hunt for that specialty’s documentation. See methotrexate? Find the rheumatology notes. Spot rituximab? Track down oncology records. The medications are breadcrumbs leading to HCC goldmines.
The Pharmacy Reconciliation Hack
We implemented something stupidly simple that changed everything. Once monthly, we run pharmacy claims against coded conditions. The gaps are shocking.
Patient filling insulin but no diabetes coded? That’s a miss. Picking up warfarin but no atrial fibrillation documented? There’s your problem. Getting monthly B12 injections but no pernicious anemia coded? Found another one.
The pharmacy data doesn’t lie. If patients are paying for medications, they have conditions worth documenting. But somehow we trust progress notes more than prescription evidence.
The Coder Training Revolution
We used to train coders on ICD-10 codes and documentation guidelines. Important, but incomplete. Now we train them on pharmacology basics. Not to diagnose, but to recognize patterns.
A coder who knows that donepezil equals dementia will dig harder when they see “cognitive decline” in notes. A coder who recognizes antiretroviral combinations will spot HIV that providers document as “immunocompromised status.”
This isn’t about coders practicing medicine. It’s about them knowing enough to find what providers have already documented somewhere. The medication list is your roadmap. Without it, you’re coding blind.
Your Wednesday Morning Exercise
Pull ten random patients who take more than five medications. List every drug. Now check what conditions you’ve coded for them. I guarantee you’ll find gaps.
That metformin-sitagliptin combo? Someone has diabetes with complications you haven’t captured. Those three cardiac meds? There’s heart failure specificity missing somewhere. The antidepressant-antipsychotic-mood stabilizer cocktail? You’re leaving thousands on the table.
Stop treating medication lists as clinical reference material. Start treating them as HCC treasure maps. Every prescription tells a story. Every refill confirms a chronic condition. Every specialist medication points to documentation you haven’t found yet.
We increased our HCC capture rate by 23% just by teaching coders to read medication lists first, documentation second. The medications never lie. They’re prescribed for reasons. Find those reasons in the documentation, and you’ll find your missing HCCs.
