CRC Risk Adjustment Models & HCCs 2 — Questions and Answers
Question 1: What happens when a diagnosis code does not map to any HCC?
- The diagnosis is rejected
- The diagnosis is stored but does not affect RAF — only HCC-mapped conditions contribute to payment (Correct answer)
- CMS assigns the nearest matching HCC
- The plan receives a default minimum payment
Correct 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.
Non-HCC codes are important for quality measure denominators, encounter data completeness, and program integrity monitoring.
Question 2: A patient has HCC 85 (Heart Failure), HCC 96 (Arrhythmias), and HCC 111 (COPD). How are these processed?
- All three are in the cardiac hierarchy; only the highest counts
- Each is in a separate hierarchy and all contribute independently, plus any interaction terms (Correct answer)
- The model selects the two highest and drops the lowest
- All combined into a composite HCC
Correct 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.
Many assume all cardiac conditions share one hierarchy, but heart failure and arrhythmias are in different hierarchies.
Question 3: What is 'trumping' in the CMS-HCC hierarchy?
- Provider's diagnosis trumps the coder's code
- Within a hierarchy, higher-severity HCCs supersede lower ones, with only the highest counted (Correct answer)
- Most recently documented condition trumps earlier ones
- Inpatient diagnoses trump outpatient
Correct 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.
Both conditions should still be coded — the hierarchy is applied during RAF calculation, not during coding.
Question 4: What is a common example of a disease interaction in CMS-HCC, and how does it affect the RAF?
- Drug-disease interactions affecting medications
- HCC pairs whose combination adds an incremental coefficient beyond individual HCC weights (Correct answer)
- Interactions between age and disease severity
- Provider-disease interactions by specialty
Correct 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.
Missing either condition in an interaction pair loses not just that HCC weight but also the interaction bonus.
Question 5: How often must chronic conditions be coded for CMS-HCC purposes?
- Once, and they persist permanently
- Every calendar year; if not recaptured, the HCC drops from following year's RAF (Correct answer)
- Every 3 years
- Once they reach HCC status, they carry forward automatically
Correct 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.
Annual recapture drives much of the risk adjustment industry's focus on gap analysis and provider education.
Question 6: How did CMS-HCC V28 change substance use disorder categorization?
- Substance use disorders were removed entirely
- V28 created more granular categories differentiating by substance type and severity (Correct answer)
- V28 combined all into a single HCC
- The change only affected payment timing
Correct 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.
Vague substance use documentation is no longer sufficient for optimal HCC capture.
CRC Risk Adjustment Models & HCCs 2
What happens when a diagnosis code does not map to any HCC?