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Since 2004, HCCs have been used by the Centers for Medicare and Medicaid Services (CMS) as part of a risk-adjustment model that identifies individuals with serious acute or chronic conditions. This allows Medicare to project the expected risk and future annual cost of care.
Hierarchical condition category (HCC) coding is a risk-adjustment model originally designed to estimate future health care costs for patients. The Centers for Medicare & Medicaid Services...
In the HCC payment models, conditions that are expected to be ongoing and/or require significant medical costs are organized into diagnostic categories called HCCs. These categories carry various weighted values called risk adjustment factors (RAFs).
What is the difference between CMS-HCC and HHS-HCC? CMS developed HCCs to pay Medicare Advantage Organizations (MAOs) differentially based on disease burden and
Medicare risk adjustment information, including: Evaluation of the CMS-HCC Risk Adjustment Model; Model diagnosis codes; Risk Adjustment model software (HCC, RxHCC, ESRD) Information on customer support for risk adjustment
The CMS HCC model filters ICD-10-CM codes into diagnosis groups and condition categories. Hierarchies or families of conditions are progressively assigned an HCC numeric code, which is translated to a risk adjustment factor (RAF) value.
CMS uses the HCCs to risk adjust the payments it makes to Medicare Advantage (MA) plans and for care provided via some demonstration projects. Typically, MA plans receive a capitated amount of money from CMS which they use to pay claims for the care that their policy holders receive.