![]() ![]() The main HCC categories are bipolar disorders, pulmonary disease, diabetes, congestive heart failure, rheumatoid arthritis, prostate & breast cancer and specified heart arrhythmias. In the HCC, conditions, and diseases are based on body systems or other similar diseases. How Disease Classification Works in HCC Coding Guidelines The HCC is so successful at predicting the use of resources and because the general trend to follow CMS direction, we expect that HCC is the model that commercial payers will use soon. Medicaid created this model in 1997 and started using it in 2004. HCC Coding is important to both practitioners and patients. The risk assessment data is based on the diagnosis information collected from medical records that are collected from physician offices, outpatient data and hospital inpatient visits. Where does the risk assessment data come from? This is what we refer to as Medicare HCC codes. HCCs pays accurately for the predicted patient cost expenditures.īy adjusting payments according to the health status and demographics of the patient. Why HCC is Important for Medical Practitioners and Patientsīasically, HCCs help CMS to reimburse Medicare Advantage plans based on their members’ health. The combination of the ACA market reforms and the RAF programs means that insurance companies focus on offering high-quality health plans at reasonable prices. It assesses each patient’s cumulative risk and designates a particular amount to them. Payment depends on a number of factors that determine the level of risk required to maintain the patient’s health.Ĭonsider the RAF program the Robin Hood of the healthcare patient model. In this payment model, two different patients in the same practice may pay different amounts for the services they receive. This ensures that the insurance premium gets transferred from healthy patients to patients with an RAF score that is below average. Usually, healthy patients have a lower than average risk adjustment factor. The risk score is a relative measure of how costly the patient is likely to be. In the Risk Adjustment model, the diagnosis and patient demographics help determine the patient’s risk score. Risk Adjustment Coding, Its Relationship to HCC and Its Importance In the next section, we look at what is risk adjustment coding. So as to better understand HCC, you should have a fundamental understanding of Risk Adjustment and in order to better understand risk adjustment, you should understand HCC. ![]() The HCC payment system uses ICD-10 codes and demographics to generate a risk adjustment factor (RAF) score which identifies patients that require a higher cost to care and is based on the diagnosis codes billed in the previous review period. In order to ensure HCC codes and documentation compliance, CMS checks health plans using targeted and random audits. It is clear that proper HCC medical coding and documentation is critical in ACOs, MA, and HVBP. With the introduction of the Medicare Advantage Plans and its requirement of RAF reimbursement scores, the HCC has become more popular.Īt the moment, every coding leader and the commercial payer is talking about HCC. The Hierarchical Condition Categories (HCC) is a risk-adjustment model that has existed for many years. So, what does HCC stand for in medical coding? However, there is no consecutive plan that everyone can follow. The role of the ACA is to ensure that patients get affordable health coverage regardless of the number of visits. These are people who rarely visit the doctor, and this ensures that they do not inflate or deny cover for ill patients. The Affordable Care Act (ACA) ensures that insurance companies don’t give healthy patients cheap insurance plans. In healthcare, however, this phrase does not apply. ![]() There is a saying that goes: “you get what you pay for.” This saying is applicable when you pay for a designer product or a vehicle. The Origin of HCC Medical Billing and Coding In this article, we will discuss everything about HCC coding, from its origin to its relationship with risk adjustment coding and its relationship with the MEAT framework. So, what is HCC in medical terms and what is HCC healthcare? This has resulted in Medicare paying a higher monthly capitation fee for patients with higher HCC scores as these require more resources and disease intervention. HCC scores have been used since 2004 by Medicare to adjust payments based on the risk level of the enrollee. ![]()
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