CMS uses HCC to compensate Medicare Advantage plans established on the health of their members. It compensates accurately for the anticipated cost expenditures of the patients by adjusting those payments based on demographic information as well as patient as their health status.

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HCC Coding Services: Achieve Accurate HCC Risk
Adjustment Coding
Hierarchical Condition Categories (HCC), a risk adjustment model that has been around for
years, but has heightened visibility since Medicare Advantage Plans started to require RAF
scores for reimbursement. Today ever commercial payer and coding leader is the eye for the
same.
Risk Adjustment - 101
The Risk Adjustment model uses a patient’s demographics which further diagnoses to
determine a risk score, which is a qualified measure of how costly that patient’s treatment is
anticipated.
Healthy patients who are below-average Risk Adjustment Factor score from the insurance
premium are transferred from healthy patients to patients with an above-average RAF score.
Under this payment model, two patients within the same practice can have a different
payment rate. This is due to the variety of factors which determines the amount of risk/work
involved to maintain the health of a patient.

2. Call now 888-357-3226 (Toll Free)
info@medicalbillersandcoders.com
www.medicalbillersandcoders.com
Copyright ©-2018 MBC. All Rights Reserved2
HCC Coding
CMS uses HCC to compensate Medicare Advantage plans established on the health of their
members. It compensates accurately for the anticipated cost expenditures of the patients by
adjusting those payments based on demographic information as well as patient as their health
status.
The risk assessment information is centered on the diagnosis data drawn from claims and
medical records collected by physician offices, hospital inpatient visits and in outpatient
settings.
Diseases and conditions are organized into body systems or similar disease processes. The
top HCC categories include:
 Asthma and pulmonary disease
 Diabetes
 Major depressive and bipolar disorders
 Congestive Heart Failure
 Specified heart arrhythmias
 Breast and prostate cancer
 Rheumatoid arthritis
 Colorectal, breast, kidney
This new risk adjustment identifies patients and establishes the financial allocation offered by
CMS towards the twelve-monthly care of every patient.
This new model is established on serious chronic health conditions. Physicians should
thoroughly report on every patient’s risk adjustment diagnosis which is based on accurate
medical record documentation.
Every detailed diagnosis is used to determine the RAF, therefore the score derived is further
used to calculate the reimbursements as well as to know the future cost associated with the
patient’s treatment.

3. Call now 888-357-3226 (Toll Free)
info@medicalbillersandcoders.com
www.medicalbillersandcoders.com
Copyright ©-2018 MBC. All Rights Reserved3
The Bottom Line
HCC coding is the great equalizer. Earlier; before the rise of the risk adjustment model,
reimbursement was based solely on demographic factors. Since costs are supposed to vary
widely in patients, HCC risk adjustment coding can now be widely used to assess patients on
the same scale.
To get more information on HCC coding and achieve HCC risk adjustment coding, get instant
access to MBC representative. Click here for more details.