Risk Adjustment
Coding

These HCC models use patient data to predict the estimated future costs for individual patients. HCC models use two primary sources of data to determine a patient’s Risk Adjustment factor (RAF), which are demographic characteristics and health status. Demographic data includes the patient’s age, gender, and other population-specific factors. The second primary data source health status is based on the ICD-10-CM diagnosis code. The CMS-HCC model is prospective, meaning the data is collected in the base year to determine expected costs for the following year (the “prediction” year). For example, data from 2020 (base year) will be used to predict expenses in 2021 (prediction year). The HHS-HCC model is concurrent, meaning the model predicts future expenditures associated with the current year’s health events.

Our experienced HCC coder will validate the medical record eligibility and assign the appropriate ICD-10 CM codes if the conditions meet TAMPER criteria (Treatment, Assessment, Monitor/Medicate, Plan, Evaluate, Referral) or MEAT criteria (Monitor, Evaluate, Assessment, Treatment). We will also identify missed RAF scoring opportunities and tackle the under-documentation issues with a solid CDI program.