HCC Coding

HCCs are increasingly used as a way to risk-adjust patients in multiple VBR programs. For example, CMS HCCs are used as a factor in calculating the total performance score (TPS) under the Hospital Value-Based Purchasing (VBP) Program, and they are often used in shared risk and shared savings program metrics.

HCC & Risk Adjustment Factor

  • HCC (Hierarchical Condition Categories) is a model implemented to adjust capitation payments to private healthcare plans for the health expenditure risk of their enrollees
  • The CMS risk adjustment model measures the disease burden that includes 79 HCC categories, which are correlated to diagnosis codes
  • The HCC model is made up of 10,000+ ICD-10 codes that typically represent costly, chronic diseases such as:
    • Diabetes
    • Chronic kidney disease
    • Congestive heart failure
    • Chronic obstructive pulmonary disease
    • Malignant neoplasms
    • Some acute conditions (MI, CVA, hip fx)

Risk Score Development

The Risk Adjustment Factor (RAF score) is set for each patient and includes:

  • Baseline demographic elements (age/sex, dual eligibility status).
  • Incremental increases based on HCC diagnoses submitted on claims from face to face encounters with qualified practitioners during the calendar year.
  • HCC coding is prospective in nature - the work you do in this year sets the RAF and subsequent funding for next year.
  • All models include chronic conditions that do not change from year to year, i.e., diabetes, COPD, CHF, Atrial-Fib, MS, Parkinson’s, Chronic Hepatitis.

Coding Team Midas IT Services

  • Our fully-employed team of certified coders can scale quickly and complete projects of any size with the maximum level of accuracy, and following a rigorous quality assurance process.
  • CPC/CRC Certified coders to perform chart review to identify all HCC conditions.
  • Coders are well versed with CMM HCC specifications and ICD-10 CM coding guidelines .
  • Certified physician auditors to ensure 98% accuracy.
  • AHIMA approved ICD-10 coding trainers.

Chart Review

  • Capturing of all HCC codes with assigned HCC condition category, Documentation must show that condition was monitored, evaluated, assessed, or treated (MEAT).
  • Follow ICD-10 Official Guidelines for Coding and Reporting. Adherence to these guidelines is required under HIPAA.
  • Coding of all ICD-10 CM codes mapped to 79 HCC categories.
  • Review of complete medical record, not only from problem list or PMH.
  • Identification of conditions which are not documented but billed.

MEAT for HCC conditions


Risk Adjustment Calculation

  • Individual risk scores are calculated by adding the coefficients associated with each members demographic and disease factors.
  • RAF calculation at the member and practice/plan level.
  • RAF improvement for each member (Last year base RAF score to be shared by client).

HCC Reporting

  • Average HCC per member within reviewed population.
  • Top 10 HCC conditions, raw data also can be shared based on client requirements.
  • Top 10 HCC conditions with higher RAF value.
  • Identification of Undocumented HCC conditions to eliminate coding compliance risks.
  • Weekly/monthly project review to share progress.
  • Project end summary with complete output details.

Output Files Submission

  • HCC output files submission in standard file format or client preferred format if any.
  • 100% quality audit on output files to reduce any data discrepancy.
  • Secure data files sharing via SFTP or encrypted files.
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