Know About HCC Coding Today’s Risk Adjustment Model

Know About HCC Coding Today’s Risk Adjustment Model HCC stands for ‘Hierarchical Condition Categories’, the risk adjustment and payment model that certain insurance companies use. Risk adjustment and HCC medical coding depend on the demographic and health status information of the patient find the risk score and determine the baseline to find how much it would cost for the insurance company to fund the healthcare. ICD-10 codes are used to identify the patient’s health condition, and they are submitted along with the claims and mapped to over 70 HCC codes in the risk adjustment model. With a high score, the health plan has a better chance of being compensated every year for the patient’s care.

HCC medical coding was implemented in the early 2000s for an easier way to identify patients with serious or chronic illnesses. ICD-10 (International Classification of Diseases-10) diagnoses are used for identifying health conditions, and these are submitted by the health provider as claims are being processed. More than 9,000 ICD-10 codes are available for mapping 79 HCC codes in the risk adjustment model. The Centers for Medicare and Medicaid Services (CMS) requires documentation on the medical record of the patient to be recorded only by a professional and qualified healthcare provider. Likewise, the documentation should support the presence of the condition, and that there should be an assessment or a plan for the management of that condition.

It is critical to note, however, that the CMS requires healthcare providers to provide documentation of the condition at least once a year. The calendar for risk adjustment starts anew every January 1. So, a patient that is covered by the insurance is considered healthy until the diagnosis code is provided on their claims. Risk adjustment data validation audits are typically conducted by CMS to ensure accurate HCC medical coding.

In case of incorrect or incomplete data, the patient’s reimbursement could be reduced or adjusted. This means you need to make sure that the coding is error-free and accurate for a smoother way to process and file claims with insurance providers. You can ensure accurate HCC medical coding with help from a team of seasoned AAPC-certified medical encoders who are trained and up-to-date on the best practices regarding HCC.