{"id":7895,"date":"2018-05-21T13:08:27","date_gmt":"2018-05-21T13:08:27","guid":{"rendered":"http:\/\/www.medicalbillersandcoders.com\/blog\/?p=7895"},"modified":"2026-05-11T14:13:12","modified_gmt":"2026-05-11T14:13:12","slug":"condition-category-hcc-coding","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/condition-category-hcc-coding\/","title":{"rendered":"Risk Adjusted Hierarchical Condition Category (HCC) Coding"},"content":{"rendered":"

HCC is a payment model created by the Balanced Budget Act of 1997. Implemented by the Center for Medicare and Medicaid Services in 2003, the payment model will identify the individual with chronic illness and assign them to a risk factor score. This risk factor score gives CMS a specific plan out that channelizes the payment method for the risked beneficiaries enrolled.<\/p>\n

The payment model is different compared to the average amount for Medicare Beneficiaries. Such risk adjustments plans provide rough data that CMS has to make appropriate and accurate payment enrollees with the difference in expected cost.<\/p>\n

In simple terms, Risk score will measure the individual beneficiary\u2019s relative risk and Medicare uses them to adjust the payment for each beneficiary on expected expenditure. Using this CMS is able to standardize the base payment to plans based on the risk factor which directly correlates to a basic condition of payment.<\/p>\n

The individual health condition is identified via the International Classification of Diseases- 10 (ICD-10).\u00a0 The diagnosis is submitted by providers on incoming claims. There are more than 9000 ICD-10<\/a> codes that map to 79 HCC codes in the risk adjustment model.<\/p>\n

The proven success of HCCs in the prediction of resources used for Medicare Advantage enrollees, could now further been implemented into determining the partial reimbursement for Accountable Care Organization (ACO) and Hospital Value-Based Purchasing (HVBP) program.<\/p>\n

Providers who admit outpatient have assumed the risk for outpatient documentation and coding.\u00a0 The risk factor score will let providers to accurately capture their patient’s health status they will receive the benefit will failing to do so will not.<\/p>\n

Risk Adjustment Affecting Payment<\/h2>\n

As the provider’s payment is now more dependent on the quality of care. It provides a more impactful solution for the providers to mask-out. Risk Adjustment involves estimating the provider\u2019s performance based on each quality to measure or the expected Medicare allowable charges on each cost measure.<\/p>\n

Risk-Adjusted Measure Score= (Actual Performance\/ Expected performance) * National Average<\/strong><\/p>\n

Risk Adjustment Process<\/h2>\n

For the 2017 modifier measure the entail a comparison of the actual performance to the other expected performance. Its implementation differs depending on a different specialty with specific risk-adjustment policy.<\/p>\n

HCC Category Description<\/h2>\n
    \n
  1. HIV \/ Aids<\/li>\n
  2. Septicemia \/ Shock<\/li>\n
  3. Opportunistic Infections<\/li>\n
  4. Metastatic Cancer And Acute Leukemia<\/li>\n
  5. Lung Upper Digestive Tract And Other Severe Cancers<\/li>\n
  6. Lymphatic Head And Neck Brain And Other Major Cancers<\/li>\n
  7. Breast Prostate Colorectal And Other Cancers And Tumors<\/li>\n
  8. Diabetes With Renal Or Peripheral Circulatory Manifestation<\/li>\n
  9. Diabetes With Neurologic Or Other Specified Manifestation<\/li>\n
  10. Diabetes With Acute Complications<\/li>\n
  11. Diabetes With Ophthalmologic Or Unspecified Manifestation<\/li>\n
  12. Diabetes Without Complication<\/li>\n
  13. Protein-Calorie Malnutrition<\/li>\n
  14. End-Stage Liver Disease<\/li>\n
  15. Cirrhosis Of Liver<\/li>\n
  16. Chronic Hepatitis<\/li>\n
  17. Intestinal Obstruction\/Perforation<\/li>\n
  18. Pancreatic Disease<\/li>\n
  19. Inflammatory Bowel Disease<\/li>\n
  20. Bone\/Joint\/Muscle Infections\/Necrosis<\/li>\n
  21. Rheumatoid Arthritis And Inflammatory Connective Tissue Disease<\/li>\n
  22. Severe Hematological Disorders<\/li>\n
  23. Disorders Of Immunity51drug \/ Alcohol Psychosis<\/li>\n
  24. Drug \/ Alcohol Dependence54schizophrenia<\/li>\n
  25. Major Depressive Bipolar And Paranoid Disorder<\/li>\n<\/ol>\n

    Risk Adjustments Data Flow<\/h2>\n

    Risk Score gives a number on the account of the risk of an individual beneficiary and calculates the payment for each beneficiary expected expenditure. Accurate risk adjustments mean to rely on the diagnosis coding derived from the patient\u2019s medical record. It\u2019s important to capture the events of the entire patient encounter.<\/p>\n

    The risk adjustment process flow is as follow:<\/h3>\n