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HCC Risk Coding

Saisystems Health Medical Coding and Billing


Hierarchical Condition Category (HCC) codes are used to represent the complexity of a patient’s health. Under value-based models, these representations are closely tied to levels of reimbursement.

The HCC codes are used with demographic information to determine the patient’s Risk Adjustment Factor (RAF) score and this score is used to predict the following year’s payment according to the Prospective Risk Adjustment and the current year’s Concurrent Risk Adjustment expenditures in a capitated model.

HCC codes are also used to set target prices under CMS APM models for the episode of care. By capturing all the risk factors associated with the patient and accurately documenting all the factors that affect medical decision making, it ensures that appropriate reimbursement is received.

Presenting a precise depiction of your patient’s health is a necessity for optimizing reimbursement for your practice.

With over 80 HCC categories tied to over 9.500 ICD-10-CM codes, accuracy can be a challenge.

Physician documentation must be reviewed to identify medical conditions and proper coding must applied to those conditions once identified.

Capturing data at the point of care with an application such as billEHR is a tactic that makes this process more efficient. Employing professional coders is a best practice takes that efficiency and adds a level of assurance.

HCC coding professionals map the documentation of the provider with the guidelines of coding and reporting given by CMS allowing the provider to focus on providing optimal care with the confidence that RAF scores and reimbursements are being reported correctly.

If your practice is limited by having only 12 ICD codes on the 1500 form contact us. We can help. Saisystems Health has over 23 years of helping providers with optimizing coding.


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