HCC Risk Adjustment Coding

News and Important Information


CMS Announces Final 2021 HCC Risk Adjustment Changes

Extrapolation Policies Apply to RAD-V Audits

Risk Adjustment Calculator (CMS-HCC Model)

HCC - Acceptable Provider Interpretation for Diagnostic Testing


CMS Medical Record Reviewer Guidance as of 03/20/2019 

CMS- Program of All-Inclusive Care for the Elderly (PACE)

Versions used by Year:

2020 they're using versions CMS22, CMS24, ESRD21Rx05

2019 they used versions CMS21, CMS22, CMS23, ESRD21Rx05

2018 they used versions CMS21, CMS22, ESRD21Rx05

2017 they used versions CMS21, CMS22, ESRD21Rx05

2016 they used versions CMS21, CMS22, ESRD21Rx05

2015 they used versions CMS12, CMS21, CMS22, ESRD21Rx03

2014 they used versions CMS12, CMS21, CMS22, ESRD21Rx03

2013 they used versions CMS12, CMS21, ESRD21Rx03

Find-A-Code Tools and Resources

HCC Risk Calculator

HCC Risk Score Calculator

HCC Codes

Hierarchical Condition Categories (HCC)

General Links and Resources

Documentation/Coding for HCC

Documentation and Coding Practices for Risk Adjustment and Hierarchical Condition Categories

Select the title to see a summary and a link to the full article.

Are Diagnoses from Telehealth Services Eligible for Risk Adjustment?


On April 10th, CMS released a memo with the subject line, “Applicability of diagnoses from telehealth services for risk adjustment,” suggesting there may be some telehealth services that might not qualify for risk adjustment. However, in the memo CMS states: “Diagnoses resulting from telehealth services can meet the risk adjustment face-to-face ...

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CMS Temporarily Suspends Contract-Level RADV Audits


The Centers for Medicare and Medicaid Services (CMS) is suspending contract-level RADV audits, related to the payment year 2015 and will not initiate any new ones until after the public health emergency has ended. Any documentation already submitted will be reviewed as usual.

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CMS Announces Final 2021 HCC Risk Adjustment Changes


On April 6, 2020, the Centers for Medicare & Medicaid Services (CMS) published their final Medicare Advantage (MA) and Part D payment methodologies for CY 2021. Read more to be prepared for these upcoming changes.

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2021 Brings Another Risk Adjustment Calculation Change


In 2021, a big change in Risk Adjustment score calculations will take place, which will affect payments to Medicare Advantage (MA) plans for the coming year and take us closer to quality and value-based programs instead of fee-for-service (FFS) or risk-adjusted (RA). Currently, CMS pays a per-enrollee capitated...

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Extrapolation Policies Apply to RAD-V Audits


Risk Adjustment is a program that was implemented to identify and support Medicare beneficiaries with health conditions, illnesses, or injuries that put them at risk of death or organ system/bodily function failure. Through Risk Adjustment (RA), Medicare ensures their beneficiaries are being followed at least annually for any healthcare conditions ...

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Access to this feature is available in the following products:
  • HCC Coder
  • Find-A-Code Professional
  • Find-A-Code Facility Base

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Risk Adjustment HCC Edition

  • Risk adjustment essentials
  • HCC risk adjustment models and ICD-10-CM crosswalks
  • Understanding and maximizing ICD-10-CM code selection
  • Provider Documentation Guides (PDGs) for better provider documentation
  • Diagnosis hierarchies
  • and more...

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