Wiki CMS HCC Coding

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Shay2025

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I just got a new position as a medicare advantage payment analyst. I am doing appeals and processing Medicare Advantage Claims. I am used to being on the other side of the billing cycle. So this is new to me. I was doing some research about Medicare Advantage plans and came across CMS HCC Coding.
Can anyone shed some light as to what this type of coding actually is in a nut shell?

I have been on the CMS website and have reviewed some of the material at a glance.


Please help
thx
 
Shay2025 said:
I just got a new position as a medicare advantage payment analyst. I am doing appeals and processing Medicare Advantage Claims. I am used to being on the other side of the billing cycle. So this is new to me. I was doing some research about Medicare Advantage plans and came across CMS HCC Coding.
Can anyone shed some light as to what this type of coding actually is in a nut shell?

I have been on the CMS website and have reviewed some of the material at a glance.


Please help
thx
Click to expand...

In a nutshell, HCC coding consists of approx. 3000 diagnosis codes related to chronic or acute health conditions (think diabetes, heart, lung, kidney, etc) that are matched to specific HCC (Hierarchal Condition Categories) categories. Medicare Advantage plans are paid by Medicare based on RAF (Risk Adjustment Factor) scores. Those scores use the HCC category codes to assign values. The sicker the patient the more money available from Medicare to pay claims for those patients under the Med Advantage plan. Each year the patients must be evaluated and the chronic conditions must be re-coded to count.

I just left a position with a small group that managed MedAdvantage plans for a network of physicians. It can get a little complicated for the physicians to keep up with.
 
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