The CMS HCC Risk Adjustment Model is a risk adjustment methodology used by the Centers for Medicare & Medicaid Services (CMS) to adjust payments to Medicare Advantage (MA) plans based on the health status and expected healthcare costs of their enrollees. HCC stands for Hierarchical Condition Categories, which are groups of medical conditions that share similar expected costs of treatment.

 

Since its inception in 2004, the CMS HCC Risk Adjustment Model, each MA enrollee is assigned a risk score based on both their demographic information, such as age and gender, as well as their medical conditions and the severity of those conditions. The risk score is calculated by first assigning HCCs to each enrollee based on their medical diagnoses, and then applying a weight to each HCC based on its expected costs of treatment. The weights are then added up to determine the enrollee’s overall risk score.

 

The CMS HCC Risk Adjustment Model is designed to account for differences in the health status and expected costs of care among MA enrollees, and to ensure that MA plans are adequately compensated for the medical needs of their enrollees. The risk adjustment methodology is used to adjust payments made to MA plans based on the enrollee’s risk score, with higher risk scores resulting in higher payments to the MA plan.

 

The CMS HCC Risk Adjustment Model is updated annually to reflect changes in the prevalence and costs of medical conditions, as well as changes in the coding and classification systems used to identify medical diagnoses.

 

What is a RAF score? 

 

The Risk Adjustment Factor (RAF) score is a measure used to adjust the payment for healthcare services based on the health status and expected medical costs of the patient. The RAF score is typically used in the context of Medicare Advantage (MA) plans, which are a type of health insurance offered by private companies that contract with Medicare to provide Medicare benefits to eligible individuals.

 

The RAF score is calculated using a formula that takes into account the patient’s demographic information, such as age and gender, as well as their medical conditions and the severity of those conditions. The formula assigns a weight to each medical condition based on its expected cost of treatment. The weights are then added up to determine the patient’s overall RAF score.

 

So a patient has a RAF of 1.5 may have a 0.6 from demographics, a 0.3 for diabetes, and 0.6 from COPD. 

 

The RAF score is used to adjust the payment made by Medicare to the MA plan for each patient. Patients with higher RAF scores are considered more expensive to treat, and the MA plan will receive a higher payment to cover the expected costs of care. This helps to ensure that MA plans are adequately compensated for the medical needs of their patients, and that patients with more complex health conditions receive appropriate care.

 

How do HCCs relate to it?

 

Each year, Medicare calculates an amount of money that will be paid per member per month (PMPM).  This same base rate is paid out for every patient, regardless of what services were done.  This base rate is then multiplied by the patient’s RAF score so that more money is payed out to take care of patients with a high RAF (sicker patients) than those with a low RAF (healthier patients).  

 

If a CMS patient has a high RAF, they he/she is expected to get extensive medical care, clinicians who enroll these are reimbursed more than those who have low RAFs. The additional reimbursement amounts for patients who qualify will not be paid to organizations that do not properly or completely document HCC codes as incorrectly documented codes do not add to the RAF score.

 

To know more about HCC coding and how to improve it, you can refer to our blog on ‘How to improve HCC coding and avoid risks.’

Healthcare providers and payers use the HCC coding system to identify the seriousness and severity of a patient’s medical condition. The main purpose of coding is to ensure that a patient receives good medical care and resources. 

 

If it is not performed correctly, then there will be some potential risks associated with HCC coding. Improper, incorrect, wrong, or incomplete coding could classify a patient as less sick, which could lead to inadequate care, improper payments to healthcare providers, or audits and fines and penalties paid to Medicare.

 

Here are some key steps that healthcare providers and coders can implement to improve HCC coding and avoid risks: – 

 

1 – Stay updated on coding guidelines – There are certain guidelines on HCC coding which can change or evolve over a period of time. It is important to stay updated with the latest guidelines, changes, and revisions. This can be achieved through regular training sessions or staying informed by reviewing resources such as CMS websites or other industry-related publications.

 

2 – Error-free documentation – Accurate and complete documentation is vital for HCC coding, as it properly identifies a patient’s condition and provides all the information that is needed by the patient and healthcare providers. In the end, all the relevant diagnoses, procedures, and treatments should accurately reflect the patient’s conditions in the coding document.

 

3  –  Regular audits – Conducting regular audits is crucial to identifying potential errors and correcting them, and to avoid penalties, so that patients get the proper treatment. Regular audits can be implemented by internal staff or by third-party auditors. This includes a review of accuracy, documentation, and compliance requirements.

 

4 – Leveraging the technology – There are numerous online tools available which can help in HCC coding, these include coding software, EHR systems, and other electronic tools. These instruments can facilitate coding, lessen errors, and help in maintaining the consistency among different coders and providers.

 

Potential risks can be avoided by staying updated on current coding guidelines, changes, and compliance requirements. This will help to improve the quality, reliability, and accuracy of HCC coding. It is an important factor that reflects a patient’s health status and ensures he/she receives proper care and resources.

 

To know more about the list of HCC codes, you can also read our blog on “What Is HCC Coding ?“

Here is the cheat sheet you’re looking for: DOWNLOAD 

 

ICD-10 codes are hard. Knowing which codes to use for Risk Adjustment in your Value-Based Care is even harder. And even the best available clinician training rarely yields lasting behavior change. Your team needs a resource in your pocket, but a cheat sheet isn’t the best available. 

 

A cheat sheet for ICD-10 codes can include a list of the codes and their descriptions, as well as common scenarios and the corresponding codes that should be used. 

 

Having a cheat sheet can also help you quickly look up any unfamiliar codes so that you can make sure you are using the correct ones. Some cheat sheets may even include helpful tips on how to use the codes, which can be very useful for those who are just learning about ICD-10 coding. 

 

So, if you are dealing with ICD-10 codes, having a cheat sheet can be a great way to stay organized and make sure you are using the correct codes.

 

Is it a cheat sheet if it helps provide better care to patients?

 

Absolutely not! First of all, it can help streamline the process of coding diagnoses and treatments. By having an easily accessible reference guide for ICD-10 codes, healthcare providers and coders can quickly look up the correct codes for their documentation. This saves time and can help ensure that all pertinent information is accurately and properly coded.

 

Secondly, an ICD-10 code cheat sheet can help to improve accuracy in medical coding. Medical coding is a complex process, and mistakes can be costly. An ICD-10 code cheat sheet can provide coders with a quick reference to ensure that they are using the correct codes for diagnoses and treatments. This can help reduce errors and improve patient care by ensuring that all relevant information is accurately and properly coded.

 

Finally, an ICD-10 code cheat sheet can help ensure that all necessary information is documented in a timely manner. By having a handy reference guide for ICD-10 codes, healthcare providers and coders can ensure that all necessary information is recorded quickly and accurately. This can help speed up the process of providing care to patients and ensure that their records are up to date.

 

In summary, an ICD-10 code cheat sheet can be a valuable tool for providing better care to patients. It can help streamline the process of coding diagnoses and treatments, improve accuracy in medical coding, and ensure that all necessary information is documented in a timely manner.

 

Why are so many clinicians searching for a cheat sheet?

 

ICD-10 codes are extremely complex and can be difficult to keep track of, and everyone wants to make their jobs easier and accurate. Clinicians too are often looking for quick and easy ways to access the codes they need quickly and easily. A ICD-10 code cheat sheet is a great way to do this. 

 

For example, there may be codes related to infectious diseases, cardiovascular diseases, etc. This cheat sheet allows clinicians to quickly find the code they need without having to search through a long list of codes. 

 

The other advantage of a ICD-10 code cheat sheet is that it can be used to check for accuracy. If a clinician suspects that a code might not be correct, they can quickly refer to the cheat sheet to double-check the code before submitting it for billing purposes. This helps ensure that the code is accurate and helps avoid any issues with billing. 

 

Get your ICD-10 code cheat sheet now!

 

Here are two simple resources that you can use to quickly and efficiently locate and select the most appropriate ICD-10 code when diagnosing chronic conditions for patients in a risk arrangement.

 

The DoctusTech HCC Quick Guide: A simple PDF with the HCC codes for the most frequently diagnosed conditions. 

 

The DoctusTech App – the best code finding lookup tool for VBC, complete with insights on connected conditions and proper documentation requirements.

 

As a healthcare provider, you know the importance of accurately and consistently documenting diagnoses, but not just to align revenue – there is a far greater reason for specific, accurate HCC coding: patient care. One thing that is often overlooked when calculating RAF scores is the simple fact that Risk Adjustment Factor is the simplest way to track a patient’s critical health: how difficult will it be to keep this patient alive? 

 

If you consider the RAF as an indicator of the life of your patient, and your patient population, then properly diagnosing, documenting, and calculating RAF makes a lot more sense. This simple number tells a complex story, and it is vital to the health and lives of your patients – which is why proper HCC documentation is critical, and having instant access to the right HCC code is of utmost importance. 

  

One way that many clinicians have traditionally done this is by using HCC (Hierarchical Condition Category) coding cheat sheets. These sheets provide a list of diagnoses and the corresponding HCC codes, making it easy for clinicians to find the right code for a particular diagnosis.

 

While HCC coding cheat sheets can be useful in the short term, relying on them too heavily can lead to problems in the long run. Here are a few reasons why you may want to consider weaning your clinicians off of HCC coding cheat sheets:

 

Cheat sheets can be outdated: HCC codes change frequently, and cheat sheets may not always be updated to reflect the most current codes. This can lead to incorrect coding, which can result in denied claims or underpayment.

 

Cheat sheets can promote a lack of understanding: Clinicians who rely heavily on cheat sheets may not take the time to fully understand how HCC coding works. This can lead to errors in coding and a lack of confidence in their coding abilities.

 

Cheat sheets can be a crutch: It’s important for clinicians to be able to code diagnoses accurately without relying on cheat sheets. This requires a strong understanding of HCC coding and the ability to think critically about how to code different diagnoses.

 

So, how can you wean your clinicians off of HCC coding cheat sheets? Here are a few suggestions:

 

Provide enhanced training: Consider offering HCC coding training to your clinicians to help them understand the coding process and develop their coding skills. This can be done through in-person training sessions or online courses.

 

Encourage critical thinking: Encourage your clinicians to think critically about how to code diagnoses and to use resources like official coding guidelines and the ICD-10 manual to help them determine the correct codes.

 

Use coding software: Many electronic health record (EHR) systems have built-in coding tools that can help clinicians determine the correct codes for diagnoses. Encourage your clinicians to use these tools to help them become more confident and accurate in their coding.

 

By taking these steps, you can help your clinicians develop strong coding skills and break their reliance on HCC coding cheat sheets. This will lead to more accurate coding, better reimbursement, and improved patient care.

We get it, HCC coding is hard: choosing the right HCC is nuanced, and can seem subjective. But when you see a patient, you are probably not reaching for a cheat sheet on how to diagnose this patient, right? How is it that HCC coding sent you searching for a cheat sheet?

 

And learning another new thing is hard, especially when the connection between caring for your patients and coding for VBC can seem tenuous at best. (It’s not, we promise.)

 

It is possible that the training you have received around HCC coding was not great. Learning HCC coding for VBC in a seminar is almost impossible – and the last several years of zoom seminars has exacerbated an already bad situation. Do you get emails with certain codes to focus on – the “Code of the Month Club” or the like? Do you occasionally get one-on-one coaching and chart reviews, but it is infrequent and perhaps does not match your learning style?

 

Knowing which code to use when diagnosing is nuanced, and the rules around HCC coding are very strict. Practicing medicine is an art, but the hard edges of HCC coding compliance and rigorous documentation are a very strict science. Less art, more math. And nobody went to medical school because they love math. And most of all, when you are moving fast to get to your patients, the last thing you want to do is dig for a code that is only meaningful for the billing department, and has very little bearing on how you treat your patients. 

 

Strategies on how to diagnose and document for VBC are not clear. It can seem like you are practicing coding and not medicine. But there is a deep truth in HCC coding that is often not communicated in training: diagnosing for risk is one of the most important steps in caring for your patients. 

 

Diagnosing for risk is a vital step in caring for your patients, and it has nothing to do with revenue. When CMS determines the guidelines around risk, a very simple metric is often overlooked: risk is just another way to say “how likely is it that this disease will kill my patient?” Risk Scores, Risk Adjustment Factors, the hierarchies within Hierarchical Condition Category coding – these are all just means of determining how dangerous and serious a condition is, and that should help you prioritize and treat your patients better, with better outcomes. And, to put it simply, better survival rates for your patients. 

 

HCC coding for Risk is just a data-centric approach to prioritizing care for your patients. Better care for the individual patient, because you captured every relevant diagnosis code, documented and planned care around those diagnoses. Better care for your entire panel, because you know the weighted risk of each patient, and can prioritize accordingly. And better care for your organization, because resources are available to provide care where it is needed most. 

 

But again, coding and documentation are daunting, and can seem insurmountable – hence, the need for a cheat sheet.

 

But what if we told you that there was hope for this situation? A brighter day is coming. 

 

Somewhere on your team, somebody is evaluating the DoctusTech HCC Coding education app, which was designed by doctors to help you master diagnosing for VBC in a fun and engaging app. And after the initial evaluation, it only takes about 5 minutes a week to achieve full HCC coding mastery. And the best part is that it’s not only NOT BORING, it’s actually engaging, competitive, and please verify this – FUN. 

 

If nobody on your team is evaluating the DoctusTech app, somebody’s got to do it. If that’s you, great – download it here, and book some time with our team to see it in action. If there’s somebody you think should be evaluating the DT app, please share it with them, they will thank you.