Hierarchical Condition Coding (HCC) is a risk adjustment model used by Centers for Medicare and Medicaid Services (CMS) for Medicare Advantage (Part C) contract rates.

Risk Adjustment is a health plan process for compensation based on the underlying health conditions.

The HCC model focuses on chronic conditions. The top chronic conditions include; Rheumatoid Arthritis, Diabetes, Breast Cancer, Prostate Cancer, Congestive Heart Failure, Depression, and Bipolar Disorder.

One of the most important factors for HCC is documentation. In a value-based system, codes pulled form the documentation determines whether the physician is properly compensated for management of the chronically ill.

The CMS HCC model relies on ICD-10-CM codes to map to HCC codes that risk adjustment patients based on their state of health. CMS has guidelines for eligible providers that include: Medical Doctor (MD), Doctor of Osteopathic Medicine (DO), Residents, and Certified Registered Nurse Practitioner (CRNP). Healthcare facilities and plans use the HCC model to understand the risk level of patients and predict patient cost.

Some examples of conditions that map to an HCC code include, but are not limited to COPD, CHF, Parkinson’s, Amputation status, HIV status, Organ transplants, and Diabetes.

Organizations use the acronym MEAT to capture diagnosis codes. MEAT stands for:

Monitoring signs, symptoms, and progression/regression

Evaluate tests results and response to treatment

Assessment of condition, order tests, referrals, and records

Treatment from medications and therapies

 

To learn more about HCC and Risk Adjustment coding, join the HCC/Risk Adjustment Toolkit Live Webinar with Ann Barnaby. The webinar will be Thursday, June 6th at 1 pm EST and will be worth 3 MMI and AAPC approved CEUs. Join here: https://mmiclasses.com/risk-adjustment-coding-certification-program/

MMI will also be releasing an HCC/Risk Adjustment Certification Training Program, for more information on the RRC Certification visit: https://mmiclasses.com/risk-adjustment-documentation-coding-certification/