Risk Adjustment
CMS-HCC Auditing
What is HCC risk adjustment?
Hierarchical Condition Category (HCC) risk adjustment uses diagnosis information and other patient characteristics to estimate expected healthcare costs. The CMS-HCC model supports Medicare Advantage payment risk adjustment. The HHS-HCC model serves the individual and small-group insurance markets under the Affordable Care Act; the models have different purposes and mappings.
How does ReviewMate support HCC audits?
ReviewMate provides a CMS-HCC auditing module with performance targets, averages and options for managing HCC reviews. Teams can connect risk adjustment review with the broader medical coding audit platform. For HHS-HCC requirements, contact ReviewMate to confirm available capabilities.
Does every diagnosis code map to an HCC?
No. HCC mapping depends on the risk adjustment model and applicable year. A diagnosis must be supported by the medical record and meet applicable coding and reporting requirements; an HCC mapping alone does not establish that a diagnosis should be reported.
For model information and official mapping resources, see CMS Medicare Advantage risk adjustment guidance. Explore the ReviewMate medical coding encoder for related coding and HCC review tools.
In addition to ReviewMate's standard features for auditing, our HCC auditing module features:
- Overridden HCCs due to the hierarchy structure are identified on the screen so the auditor can readily see which diagnosis codes will be considered into the patient's score.
- Original, revised and net HCC weight for each calendar year.
- Each calendar year for each patient has an “Analyzer” button where the auditor can view what diagnoses and HCCs are missing for a particular calendar year.
- Discover missing encounters in order to capture necessary HCCs.
- Conduct muti-year HCC audit in one review.
All auditing account types are considered part of the core of ReviewMate's auditing system that covers many features such as:
- Customizable settings for analyzing overall accuracy rates. Adjust for particular coders, tasks or firms.
- Built-in code look-up for performing research intuitively.
- Conversations between the auditor and coder are saved in a chronological manner and can be accessed by any user.
- Customizable dashboards to enhance the user experience.
- Identification on the screen of codes with CMS-HCC values.
- Grouping and pricing take place within the software eliminating the need for auditor to "toggle" between an encoder and ReviewMate for better resequencing decisions.
- Full suite of edits/warnings including gender and age conflicts, MCE edits, critical error and TruCode warnings.
- Accuracy rates available real-time and can be sliced and diced to accommodate different situations and date patterns.
- Multiple user levels allow view-only access to any interested parties providing transparency within your organization.
- Full suite of references including Coding Clinic, CPT Assistant, Coding Clinic for HCPCS, Clinotes, Principal Diagnosis Analysis, DRG Analysis, and AHA Coding Handbook
- Reconciliation of rebuttals occurs inside of ReviewMate.
- Extensive library of customizable and exportable reports from raw data to Executive Summaries.
- "Audit the Auditor" available for a higher-level quality check of any audit in ReviewMate.