CRC Risk Adjustment Models & HCCs 2

Question 1

What happens when a diagnosis code does not map to any HCC?

Accepted Answer

The diagnosis is stored but does not affect RAF — only HCC-mapped conditions contribute to payment

Answer

Approximately 9,500 of 70,000+ ICD-10-CM codes map to HCCs. Non-HCC codes are still submitted for completeness and quality measurement.

Question 2

A patient has HCC 85 (Heart Failure), HCC 96 (Arrhythmias), and HCC 111 (COPD). How are these processed?

Accepted Answer

Each is in a separate hierarchy and all contribute independently, plus any interaction terms

Answer

These HCCs belong to different hierarchies. All three weights are additive, and disease interactions may add additional value.

Question 3

What is 'trumping' in the CMS-HCC hierarchy?

Accepted Answer

Within a hierarchy, higher-severity HCCs supersede lower ones, with only the highest counted

Answer

Trumping prevents double-counting of related conditions at different severity levels within the same hierarchy.

Question 4

What is a common example of a disease interaction in CMS-HCC, and how does it affect the RAF?

Accepted Answer

HCC pairs whose combination adds an incremental coefficient beyond individual HCC weights

Answer

Certain HCC combinations generate additional RAF increments because the combination predicts costs higher than the sum of individual weights.

Question 5

How often must chronic conditions be coded for CMS-HCC purposes?

Accepted Answer

Every calendar year; if not recaptured, the HCC drops from following year's RAF

Answer

The prospective model requires annual documentation. A condition not recaptured in 2025 is lost from 2026 payment.

(CRC) Certified Risk Adjustment Coder Practice Test