Chapter 1 of the manual may be any of the 3 types of ma plans ccp, pffs, or msa plan, and are subject to the payment rules pertaining to the plan type. Risk adjustment 101 participant guide cssc operations. The coders playbook for success with risk adjustment payment methodologies angela carmichael, mba, rhia, cdip, ccs, ccsp, crc. Documentation and coding practices for risk adjustment ahima bok.
This participant guide is designed as the foundation of the training program. Risk adjustmenthcc coderauditor course this highly specialized online course is brought to you through a collaboration between ahima and marsi. Risk adjustment training peninsula professional coders. Providing information to the healthcare compliance. Documentation and coding practices for risk adjustment and. Risk adjustment coding and hcc guide page optimization. Beginning in january 2004, the centers for medicare and medicaid services cms adopted a new reimbursement methodology based on the members health status. Cms uses hccs as a factor in calculating the total performance score under the hospital valuebased purchasing program to risk adjust the medicare spending per beneficiary. The materials provided in this training include this participant guide and. This is the official health plan training manual for part c. An excellent resource for risk adjustment coding training is the cms 2008 risk adjustment data technical assistance for medicare advantage organizations participant guide.
See chapter 4, 42 cfr 90 for definitions and guidance on national coverage. Health care compliance strategies hccs compliance and. The cms chronic conditions data warehouse ccw provides researchers with medicare and medicaid beneficiary, claims, and assessment data linked by beneficiary across the continuum. With specialization in hcc coding comes a higher salary. Hcc risk model, please refer to the medicare managed care manual chapter 7. Reimbursement model rafhcc rafhcc is a predictive model cms uses. In 2003, we transformed the cms program manuals into a web user. Preliminary icd10cm codes for cmshcc and rxhcc models. The hcc model is everchanging the original dcghcc model in 2000 identified 804 costly diagnosis groups, mapped to 189 hcc codes created a reporting model for reimbursement. The hcc model used for ma patients categorizes icd9cm diagnosis codes into disease groups that are similar both clinically and financially. This guide outlines everything from methodology to risk score verification.
When cms first implemented risk adjustment, hospital inpatient diagnoses were. Cms runs hcc risk model 3 times a year to calculate. The cmshcc risk adjustment payment model incorporates disease groups that have a significant impact on part c expenditures. Develop a thorough understanding of icd10cm guidelines including coding clinic and cms 2008 participant guide understand how to apply guidelines to medical chart documentation develop familiarity with diseases by icd10cm section and by hcc, and identify which diseases risk adjustment. Hcc stands for hierarchical condition categories, which are diagnosis groupers that convey illness burden. For the last 20 years, barbie has worked alongside physicians in nonclinical roles of support. Chapter 8 payments to medicare advantage organizations. The coders playbook for success with risk adjustment. Risk adjustment of medicare capitation payments using the. For example, for 2010 initial risk scores, cms used july 1, 2008. For example, there are more than a dozen diagnoses. The cms recently revised the index to include 79 hcc condition categories. For healthcare organizations looking to ensure they remain compliant, having the proper tools and training is.
Cms creates a hierarchy so that patients conditions are coded for the most severe manifestation among related diseases. Cms has an rx hcc model for risk adjustment of medicare part d medicare based on age 65 or older current year. Hcc coding training introduction to risk adjustment part 2 medicare advantage start to current enrollment numbers as of 2014, there is an estimated 54 million people in medicare. This document contains the 2016 cmshcc mappings in icd10, along with the risk.
Risk adjustment basics 2019 optum360, llc 11 msdrg compared to hcc there is an increasing need for hospital inpatient coders to learn. It includes the hcc category descriptions, along with the hcc code and associated disease hierarchy. Develop a thorough understanding of icd10cm guidelines including coding clinic and cms 2008 participant guide understand how to apply guidelines to medical chart documentation develop. Scan is committed to providing its provider partners quality educational materials regarding coding and documentation and its importance in the cms hcc risk adjustment payment. Centers for medicare and medicaid services cms cms document archive. From 20042016, the cmshcc model has included separate risk scores for new enrollees, longterm institutional beneficiaries, and community beneficiaries. The hierarchical condition category is a diagnosis grouping with a single relative. Understand how to apply guidelines to medical chart documentation 3. Throughout your training you will encounter familiar icons.
Top 10 medicare risk adjustment coding errors aapc. Please direct questions or concerns related to this training material to. Hcpro offers expert advice and solutions in most aspects of healthcare. Submitters can resubmit previously submitted data that was rejected. Centers for medicare and medicaid services cms office. The centers for medicare and medicaid cms risk adjustment model measures the disease burden that includes 70 hcc categories, which are. The calculator includes 20082018 payment year factors.
None of these ccs are included in the cmshcc model. As of march 16, 2020, cms updated the medicare advantage frontend system reference data to include the following value codes. Risk adjustment coding, hedis, and documentation tips. The hccs that will be dropped is identified in the disease hierarchy column. Hcpro is the leader in providing information to the healthcare compliance, regulation, and management industry. Risk adjustment 101 participant guide introduction 1 introduction. The cms hcc risk adjustment models are used to calculate risk scores, which predict. The cms online manual system is used by cms program components, partners, contractors, and state survey agencies to administer cms programs. It offers daytoday operating instructions, policies, and procedures based on statutes and regulations, guidelines, models, and directives. Cc 129, esrd is defined by medicare entitlement status. Providers and insurance companies are actually looking for specialty certified coders. Examining the association between comorbidity indexes and. Light bulb on the left, you will find your light bulb icon. Hcc s lump 3,100 diagnoses from the icd9cm system into about 70 diagnostic groups.
Cmshcc model description of the cmshcc model additional resources. Her experiences include front office management, billing and coding, and practice. The table includes the hcc category descriptions along with the hcc code and associated disease hierarchy. Hcc coding training risk adjustment training course.