Risk Adjustment and Hierarchical Condition Category (HCC) coding is a payment model mandated by the Centers for Medicare and Medicaid Services (CMS). This model identifies individuals with serious or chronic illness and assigns a risk factor score to the person based upon a combination of the individual’s health conditions and demographic details.
HCC coding relies on ICD-10-CM coding to assign risk scores to patients. Each HCC is mapped to an ICD-10-CM code. Along with demographic factors such as age and gender, insurance companies use HCC coding to assign patients a risk adjustment factor (RAF) score.
Since Risk adjustment scores reset every year, Providers need to report active diagnoses on annual basis including chronic conditions. That is why conducting annual wellness visit provides a great opportunity to capture all appropriate diagnoses.
Coding Guidelines
Coding should always comply with ICD-10-CM Coding Guidelines. Coders need to code to the highest level of specificity and ensure that the diagnoses are properly sequenced on the claim. Also, coders need to remember that conditions that were previously treated and no longer exist should not be coded.
Telling an effective story
The words and phrases that provides write in clinical documentation are the means to convey a convincing and understandable story about their patient. Documentation must support the presence of the condition and indicate the provider’s assessment and/or plan for management of the condition. Effective narrative is an art that can be learned with some practice.