HCC stands for ‘hierarchical condition category’, and it is a payment model required by certain insurance companies. Both HCC medical coding and risk adjustment rely on the health status and demographic information of a patient to determine the risk core and establish the baseline when figuring how much it would cost to fund the patient’s healthcare. The health condition of the patient is identified via ICD-10 codes, which are submitted on claims and mapped to more than 70 HCC codes in a risk adjustment model. The higher the score, the more a health plan is compensated per year for the care for that patient.
The risk adjustment and HCC Medical coding model was implemented in 2003 to identify individuals with chronic or serious illnesses. Health conditions are identified using the International Classification of Diseases-10 (ICD-10) diagnoses, which are submitted by a health provider when processing claims. Over 9,000 ICD-10 codes map to 79 HCC codes in Risk Adjustment. CSM requires that documentation on a patient’s medical record to be recorded only by a qualified healthcare provider, and that it must support the condition’s presence, while indicating the plan or assessment for managing that condition.
CMS (Centers for Medicare and Medicaid Services), however, requires documentation of a condition at least once per year. The risk adjustment calendar refreshes every January 1 where all patients covered by insurance are considered healthy until a diagnosis code is reported on their claims. CMS typically conducts risk adjustment data validation audits to ensure the accuracy of HCC medical coding. If found incomplete or incorrect, reimbursement for the patient could be adjusted or minimized.
HCC medical coding must be accurate and error-free to ensure a smoother process of filing claims with insurance providers. You can outsource the service to a seasoned team of medical coders who are AAPC-certified. A specialized team of HCC medical coders will help ensure accuracy and precision in your reports.