Risk Adjustment FAQs

Risk Adjustment FAQs

HCC Coding is an essential part of maximizing your reimbursements and a big part of that is proper risk adjustment. If you are not well versed in all things risk adjustment, it’s time to learn. Keep reading to learn more about risk adjustment with the help of the HCC Coders team.

What is risk adjustment?

Risk adjustment is a tool that levels the playing field amongst health insurers. It does this by relegating funds from plans with lower-risk enrollees to those with higher-risk enrollees. These models predict healthcare costs based on the risk of enrollees and assign a risk adjustment score to each individual based on their health status and demographics.

Why is risk adjustment important?

Risk adjustment is essential for maintaining equality in health care. Without risk adjustment, health plans would only want to enroll lower-risk individuals or charge higher-risk individuals more to maximize their profits. With risk adjustment models, the effect of adverse selection is mitigated and premiums are more stable across groups.

What are Hierarchical Condition Categories or HCCs?

Risk adjustment models use diagnoses and demographic information to predict what medical expenses will be for groups. The HCC risk adjustment model groups ICD-10-CM codes into organized categories (HCC) that create diagnostic profiles. These profiles are what are used to differentiate high-cost and low-cost individuals.

How is an HCC determined?

An HCC is determined first by looking at all ICD-10-CM codes and grouping them into diagnostic-related groups. Each code maps to a single DRG, which are then further grouped into Condition Categories (CC). Hierarchies are imposed among related CCs, which means that people are coded for only the most severe manifestation among their related diseases. CCs, thus become HCCs after hierarchies are imposed.

Contact HCC Coders today for help with your risk adjustment questions!

If you need help with risk adjustment coding, HCC Coders is here to help. We have been in the coding business for 28 and are happy to help with all of your HCC and ICD-10 coding needs. Our skilled team of coders knows the ins and outs of risk adjustment coding and they can handle projects of any size. Whether you are looking for someone to audit already completed work or want to outsource all of your risk adjustment coding, we can help. Give us a call today at 877-328-2343 to discuss your needs and obtain a quote.

To learn more about the reliable and quality HCC coding services that we offer, visit us on the web at HCC Coders.