The cms hcc model is a prospective risk adjustment tool implemented by cms in 2004 to estimate future expenditures for medicare beneficiaries. She has a history of dvt and peripheral vascular disease. This manual chapter addresses the policies and operations related to. Similar to traditional coding practicesused for reimbursement, statistics, and researchall the conditions for a particular episode of care inpatient admission, clinic visit, sameday surgery, etc. Complete guide to cmshcc risk scores aka raf scores and. Medicare risk adjustment coding hcc diagnosis codes. Primarily used for medicare advantage part c reimbursement.
The best practices and guidelines for risk adjustment and icd10cm coding document was created to highlight key medical record issues, as well as icd10cm diagnosis coding guidance, to meet or exceed cms hcc diagnosis. Proper coding for risk adjustment helps reduce healthcare. The best practices and guidelines for risk adjustment and icd10cm coding document was created by. Physicians should claim only the credit commensurate. Medicare managed care manual chapter 7 risk adjustment. Reducing medicare advantage overpayments committee for a. Submit all required diagnosis codes for each beneficiary and submit unique diagnoses at. Despite the differences, people using those three terms are referring to the same thing. Surgery, therapy, procedure, counseling, education, dme ordered given, labs ordered acknowledginggiving statuslevel of condition orderingreferencing labsother tests prescribing medication plan for management or followup of condition.
It is intended to be used as informational by individuals participating in anthems medicare advantage plans. In risk adjustment models diagnosis codes carry a risk adjustment value raf in the hcc model similar to the concept of rvu assigned to cpt codes the more severe or complex a diagnosis, the higher its value. Ensure the accuracy and integrity of risk adjustment data submitted to cms. Introduction to risk adjustment and hcc coding youtube. The goal of risk adjustment is to enable more accurate comparisons across networks that treat beneficiaries of varying clinical complexity. The draft cms hcc risk adjustment payment model was released on march 29, 2002. Physician claims data is the largest source of medical data for the risk adjustment models which help to determine how resources are allotted for care of the population.
Diagnoses from telehealth services for risk adjustment. Also listed on this slide are some web links to access additional medicare risk adjustment information. Documentation and coding practices for risk adjustment and hierarchical condition categories. Important hcc risk adjustment documentation and coding topics are discussed from both the payers and the providers perspectives. Medicare adopted risk adjustment hcc model assigns a value to each diagnosis code that is. Risk adjustment and hierarchical condition category hcc coding is a payment model mandated by the centers for medicare and medicaid.
Risk adjustment is the method used to adjust bidding and payment to health plans based on demographics i. Attempting to ensure chs has a way to quantify the certainty that codes submitted to cms are supported by medical record documentation. Learning objectives what you need to know and why about hcc coding. Cms did not update its coding adjustment estimate in 2011 and 2012 to include. The credibility adjustment factors published in the medicare mlr final rule cms4173f. The cms hcc risk adjustment payment model incorporates disease groups that have a significant impact on part c expenditures. The current version of the cms risk model is the 2020 cms hcc. Understanding and coding medicare advantage preventive. Risk adjustment frequently asked questions for providers. Risk adjustment coding and hcc guide optum360 coding. It gauges the risk that a member will incur medical expenses above or below an overall average over a defined period of time. It is intended for use only by contracted health care prof essionals participating in anthems medicare advantage plans.
Medicare ra cms hcc hierarchical condition category model is. This publication contains proprietary information of anthem, inc. Three synonymous terms refer to the same output from the cms hcc model. Compliance goals in risk adjustment coding presenters bio. For beneficiaries who do not have one of these conditions, we use prospective risk adjustment, a feature of the current cms hcc model. In hcc coding, the risk adjustment coding professional codes all conditions for the episode of care like traditional coding. Risk adjustment v2 presentation florida society acofp. Medicare risk adjustment, documentation and coding.
Attempting to ensure only documents valid for risk adjustment are used for coding 3. Hcc coding for specialty providers kettering physician partners. Cigna medicare 2020 best practices and guidelines for risk. The model is dependent on accurate documentation and coding by pcps 17 from.
Identifying suspect health conditions in medicare risk. Proficiency in all coding applications such as cpt, hcpcs, icd10, and related coding guidelines and regulations. Medicare risk adjustment, documentation and coding guidance. Associate vice president, risk adjustment job in beaverton. Risk adjustment basics 2019 optum360, llc 11 msdrg compared to hcc there is an increasing need for hospital inpatient coders to learn the outpatient coding rules in order to properly capture and report hcc diagnoses, as hospitals frequently acquire. Documentation and coding practices for risk adjustment and. Medicare advantage health plans to improve patient care through the. Hhs risk adjustment model, may 7, 2012 center for consumer information and insurance. Now your organization will have a guide that provides both the big picture and the fine detail needed to document, code, and report essential. Records should reflect a practitioners clinical thought process, coding and documenting the status and treatment of all conditions affecting the patient to the most specific level. Disclaimer the information presented herein is for information purposes only.
Jones is a 70 yearold female who comes in today for her follow up of her diabetes and copd. Optum360 risk adjustment coding and hcc guide 2021. Recognize the differences between the 2019 and 2020 cms. The purpose is so that centers for medicare and medicaid services cms can pay plans for the risk of the beneficiaries they enroll, instead of calculating an average amount for medicare medicare. Learn the concepts of risk adjustment and hcc coding from the leader in risk adjustment training. Incorrect hcc coding and risk adjustment documentation along with nonspecific diagnoses can negatively affect reimbursement, which in turn can negatively impact patient. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Hims bmgbumg documentation and coding education team has prepared this education using banner health ethics. Risk adjustment coding and hcc guide 2018 optum360, llc 59 coding scenario 1 patient name. Risk adjustment 101 participant guide cssc operations. The coding institute risk adjustment primer e book. Impact of hcc coding on primary care and specialty practices. This, however, will need to change as the medicare.
The risk adjustment coding and hcc guide 2021 ebook brings together hardtofind information about risk adjustment ra coding and hierarchical condition categories hccs in a new comprehensive resource that explains this complex reimbursement methodology. Medicare risk adjustment is prospective, meaning diagnoses from the previous year and demographic information are used to predict future costs, and adjust payment. Now your organization will have a guide that provides both the big picture and the fine detail needed to document, code, and report. Dott campo, rhia, crc manager, risk adjustment division at reimbursement management consultants, inc. Icd10cm codes are mapped to diagnosis groups, then condition.
Specificity of diagnosis coding is substantiated by the medical record. Risk adjustment 101 trillium community health plan. Raf hcc is a predictive model using diagnosis submitted. We will implement an ma coding pattern difference adjustment of 5. At that time they identified 804 costly diagnosis groups, mapped to 189 hcc codes.
Campo performs risk adjustment hcc coding and auditing, as well as education for coders and providers. Risk adjustment is a method to offset the cost of providing health insurance for individualssuch as those with chronic health conditionswho. Use diagnosis codes to determine potential patientlevel risks o. Documentation improvement, as well as risk adjustmenthcc coding round out her areas of focus at. Proficiency with diagnostic coding and how it relates to the medicare risk adjustment data submissions, claims submissions and claims payments. Formsreportsandotherresourcesdownloadsramarch31whitepaper032416. In 20, cms announced an updated, clinically revised cms hcc risk adjustment model that differs from the proposed model. Accurate coding helps to best reflect the cost of caring for memberspatients. Category cms hcc risk adjuster with the charlson and elixhauser comorbidity measures in predicting mortality. Risk adjustment is a form of predictive modeling introduced by the medicare modernization act of 2003.
Risk adjustment is a statistical methodology used to compare the. The coders playbook for success with risk adjustment. Accurate risk adjustment coding will continue to increase in importance. Reference the icd9cm and icd10cm codebooks, cms hcc risk adjustment model v22, and aha coding clinic for complete code sets and official coding guidance. Ma plans medicare advantage plan radv risk adjustment data validaton 31. Where you can find ma ra model codes and additional information on esrd and rxhcc codes and weights. Introduction to medicare advantage risk adjustment. Risk adjustmenthcc coding and documentation moda health. Created a reporting model for reimbursement based on icd9 codes. A value is assigned to each diagnosis in the model called a risk adjustment factor raf. This presentation contains proprietary information of anthem, inc. Accurate hcc medicare risk adjustment coding is necessary to receive appropriate compensation and ensure positive outcomes for patients enrolled in a medicare advantage plan. Medicare advantage plans have been using the hierarchical condition category hcc risk adjustment model since 2004.
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