![]() The following should be adhered to when coding:Īll ICD-10-CM coding assignments should be based on the ICD-10-CM Official Guidelines for Coding and Reporting for the current fiscal year. An ICD-10-CM code can map to more than one HCC, because ICD-10-CM contains combination codes (i.e., a code can represent two diagnoses or a diagnosis with a complication).Īt the foundation of HCCs is accurate coding of the ICD-10-CM diagnosis code based on the documentation found in the medical record. For consideration, there are more than 9,500 ICD-10-CM diagnosis codes that map to one or more of the 79 HCC codes in the CMS-HCC Risk Adjustment model. The structure is then further divided so that the groups break down into similar predictive costs for the beneficiaries’ future healthcare costs. In the HCC system structure, patients are placed into categories based on the ICD-10-CM diagnosis code assignment the ICD-10-CM code assignments group patients who are clinically similar into the same group (HCC). ![]() The majority of conditions submitted for HCCs are chronic conditions (a few acute conditions qualify as well) that the patient has, which have been documented by the provider with ICD-10-CM diagnosis code(s) submitted on the claim form. Of note, like any other CMS reimbursement methodology, the HCC Risk Adjustment Factor platform is subject to audit by CMS and its contractors. It is a predictive model - based on medical record documentation and submitted ICD-10-CM diagnosis codes for the plan enrollees - with an underlying purpose to adjust capitated payments made to providers in these plans based on the beneficiaries’ health. Since its inception, the understanding and significance of HCCs has grown and taken on considerable financial importance for physicians, physician groups (and physician extenders), health systems, and Medicare Advantage plans.ĬMS defines HCCs as a risk adjustment model used to calculate risk scores to predict future healthcare costs. The implementation of HCCs by CMS for the Medicare Advantage plans began in 2000, and they have been steadily phasing in this process over time. The Centers for Medicare & Medicaid Services (CMS) introduced Hierarchical Condition Categories (HCCs) and the architecture of the Risk Adjustment Factor with their mandate in 1997. Lisa Knowles ( is a Compliance, Education and Privacy Officer at Harmony Healthcare in Tampa, FL.
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