Risk Adjustment Models & HCCs Flashcards
6 cards from real CRC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Risk Adjustment Models & HCCs flashcards as text
What happens when a diagnosis code does not map to any HCC?
Answer: The diagnosis is stored but does not affect RAF — only HCC-mapped conditions contribute to payment
Approximately 9,500 of 70,000+ ICD-10-CM codes map to HCCs. Non-HCC codes are still submitted for completeness and quality measurement.
A patient has HCC 85 (Heart Failure), HCC 96 (Arrhythmias), and HCC 111 (COPD). How are these processed?
Answer: Each is in a separate hierarchy and all contribute independently, plus any interaction terms
These HCCs belong to different hierarchies. All three weights are additive, and disease interactions may add additional value.
What is 'trumping' in the CMS-HCC hierarchy?
Answer: Within a hierarchy, higher-severity HCCs supersede lower ones, with only the highest counted
Trumping prevents double-counting of related conditions at different severity levels within the same hierarchy.
What is a common example of a disease interaction in CMS-HCC, and how does it affect the RAF?
Answer: HCC pairs whose combination adds an incremental coefficient beyond individual HCC weights
Certain HCC combinations generate additional RAF increments because the combination predicts costs higher than the sum of individual weights.
How often must chronic conditions be coded for CMS-HCC purposes?
Answer: Every calendar year; if not recaptured, the HCC drops from following year's RAF
The prospective model requires annual documentation. A condition not recaptured in 2025 is lost from 2026 payment.
How did CMS-HCC V28 change substance use disorder categorization?
Answer: V28 created more granular categories differentiating by substance type and severity
V28 recognizes that different substances and severity levels predict different cost patterns, requiring more specific coding.