Inferscience offers the best HCC Coding & HCC Risk Adjustment Services in Newton, MA. In this PDF, we share Medicare Advantage and HCC Risk Adjustment. The Medicare Advantage Program, since its inception in 2003, has grown in popularity and has played a crucial role in the delivery of Medicare and reimbursement services to beneficiaries. While various risk assessment models are available in the health sector for risk adjustment assessment, the Medicare Advantage Program maintains the use of the hierarchical condition categories (HCC) coding-based model for the assessment of risk adjustment factor scores in the prediction of healthcare costs for patients. Visit our website for more information about our HCC coding services in Newton, MA.

1. Medicare Advantage and HCC Risk Adjustment
The Medicare Advantage Program, since its inception in 2003, has grown in popularity and has
played a crucial role in the delivery of Medicare and reimbursement services to beneficiaries.
While various risk assessment models are available in the health sector for risk adjustment
assessment, the Medicare Advantage Program maintains the use of the hierarchical condition
categories (HCC) coding-based model for the assessment of risk adjustment factor scores in the
prediction of healthcare costs for patients.
The HCC model of risk adjustment factor score was introduced in 2004 by the Centers for
Medicare & Medicaid Services (CMS) to more accurately estimate healthcare expenses for each
patient and boost the precision of risk adjustment data for reimbursement requests.
The HCC model is based on the set of codes mapped out by ICD-10. The diagnoses, symptoms,
and other information clinicians and other healthcare providers use to label and bill for medical
services are classified using the ICD-10 coding system. To determine the risk adjustment score
of a patient, CMS matches an ICD-10 code to precisely one HCC. Insurance companies calculate
risk-adjustment factors (RAF) for patients with HCC scores and sociodemographic
characteristics, including age and gender.
Understanding the basics of HCC coding and its importance to the determination of the risk
adjustment factor score has led many healthcare organizations to the realization of the need
for medical coders in the team that are knowledgeable in HCC medical coding and risk
adjustment coding. There is a need for consistent, accurate, and thorough coding of medical
conditions, especially those of HCC value, like chronic conditions. It is a significant determinant

2. of healthcare outcomes, costs, and reimbursements. Accurate coding of medical conditions is
also important because of the shift of the healthcare system towards value-based care. There is
also a need for physicians to understand the impact of HCC coding on reimbursement for better
documentation.
Efficient documentation is of paramount importance to the increment of risk adjustment factor
scores and the reimbursement of medical services for beneficiaries. The onus of effective
documentation lies on the team as a whole and not just the physicians, as there is a need for a
collaborative workflow in healthcare services. As a result, a dedicated workgroup should be
responsible for improving documentation. The workgroup must ensure medical
documentations effectively depict the patient’s medical needs and diagnoses to prevail in
value-based contracts. Establishing a good health profile for optimal reimbursement involves
the provision of documentation that indicates the management, evaluation, assessment, and
treatment plans (M.E.A.T) of the medical conditions.
A precise RAF score will improve government financing, but to obtain better scores, providers
must first have all the necessary tools and information for proper documentation. There is a
need in the industry for software tools to support doctors’ efforts to improve HCC
documentation and reduce the time that would take, as documentation can often be too
overwhelming and time-consuming. Such software is Inferscience’s HCC coding application,
which is designed to relieve physicians, coders, and other members of the healthcare team of
their burden by optimizing HCC coding risk adjustment documentation.
Inferscience’s HCC assistant is a cloud-based software for smart HCC coding, billing, and
documentation with full EHRs integrations. This software is essential for optimal RAF score and
reimbursement as it provides real-time analysis performed on patient data giving the
practitioner prompt advice on HCC coding and reducing hours spent looking up and
documenting.
Inferscience also provides robust reporting, which involves keeping tabs on the healthcare
providers who use the tool and allows tracking of the utilization of the tool. It also fosters
communication between organization leaders and provider teams to work together to improve
the organization’s HCC risk adjustment processes.
Also, there is a need for the comparison of yearly RAF scores to see their impact on healthcare
organizations’ reimbursement and funding and also to draw informed conclusions on how to
improve the RAF score going forward. There is a need for getting your entire team, from
physicians to financial workers, to work together in improving patient care, RAF score, and
effective reimbursement requests.