Risk Adjustment and Hierarchical Condition Category (HCC) coding is a payment model mandated by the Centers for Medicare and Medicaid Services (CMS) in 1997. Implemented in 2003, this model identifies individuals suffering from chronic illness and assigns a risk factor score to the person based upon a combination of the individual’s health conditions and demographic details. The individual’s health conditions are identified through the International Classification of Diseases –10 cm (ICD –10cm) diagnoses that are submitted by providers on incoming claims. There are more than 9000 ICD-10 codes that map to 79 HCC codes in the Risk Adjustment model.
Centers for Medicare and Medicaid Services (CMS) warrant documentation in the person’s medical record by a qualified health care provider to support the submitted diagnosis. Documentation must support the presence of the condition and indicate the provider’s assessment and/or plan for the management of the condition. This must occur at least once each calendar year in order for CMS to recognize the individual continues to have the condition.
Our proficient HCC coders assign HCC and RX HCC codes for Medicare advantage plans from the visits of the previous year visits which helps for good RAF scoring and premium adjustment for a risk population.