Risk Adjustment and Hierarchical Condition Category Coding Seminar

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 with serious or 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 via International Classification of Diseases – 10 (ICD –10) 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.

CMS requires 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 management of the condition. This activity must occur at least once each calendar year, in order for CMS to recognize the individual continues to have the condition. ICP recommends that Primary Care Practices review their panel and ensure annual wellness visits are scheduled, during which the HCC codes may be captured as appropriate. The better our risk coding, the better our evidence of quality care delivery to the patients within our integrated network.

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Integrated Care Partners