Hayes' Healthcare Blog

HCC model: Down to the Basics from Coding to Documentation

Posted by Johanna Legaspi on March 30, 2016 at 9:00 AM

The Basics

Hierarchical Condition Categories (HCC) were mandated in 1997 by the Centers for Medicare and Medicaid Services (CMS) and have been the basis for reimbursement for Medicare Advantage plans (MA) since 2004. HCCs use data to prospectively estimate predicted costs for enrolled members during the next year of coverage. These estimates are based on demographic information such as age and major medical conditions documented in the previous 12-month period. They are used to adjust Medicare capitation payments to Medicare Advantage health plans based on the anticipated risk of enrollees calculated from relevant ICD-10-CM codes.

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Topics: compliance, HCC, Coding and Documentation

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