But recent enforcement actions involving Medicare Advantage plans’ schemes to increase HCC scores are a caution against overly aggressive initiatives. To that end, many ACOs educate providers regarding HCCs and appropriate documentation and coding. Thus, if ACO providers do not list all pertinent diagnoses on their claims due to inadequate documentation or coding errors, it will be more difficult for the ACO to achieve shared savings.
CMS assigns a weight to each HCC, representing the predicted impact of that condition on a beneficiary’s total cost of care.įor an accountable care organization (ACO) participating in the MSSP, having a higher overall risk score translates into a higher benchmark for expenditures, while a lower score means a lower benchmark. Each HCC is mapped to several ICD-10 codes, although less than 15% of all ICD-10 codes are mapped to an HCC. CMS recognizes 79 HCCs, each tied to a chronic health condition likely to affect long-term health expenditures. HCCs are derived from ICD-10 codes through a retrospective review of claims data. For the Medicare Shared Savings Program (MSSP), the Centers for Medicare & Medicaid Services (CMS) uses a risk adjustment methodology called Hierarchical Condition Categories (HCCs), the same methodology used for the Medicare Advantage program. Risk adjustment is the process of modifying payments and benchmarks to reflect the degree of illness in a specific patient population.