HCC/RAF Scoring in Value Based Care Programs

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Generally, Medicare Part C (Medicare Advantage Patient Population) uses HCC/RAF scoring for the compensation paid from Medicare to Medcare Advantage Plan Payers.  Although it is important to keep in mind that using the HCC/RAF scoring and ICD-10 code mapping is also applicable to Primary Care Providers.  As we move to Value Based Care Risk Sharing Models, by 2025, you will see more and more different risk sharing models developed by Medicare.

Now is the time to start using HCC/RAF scoring for your Medicare patient population, your organization will also become stronger ICD-10 coders as part of the process.

One of the key ideas for starting to think about this new coding and scoring process is to work towards more complete ICD-10 code records in your EMR.  An example of this would be obesity.  Commonly you will find that Obesity & BMI are recorded in the clinical chart note within the EMR, although the ICD-10 code is not recorded in the problem list.  Doing this will provide better reporting for management of Obesity in your organization.  Working through adding co-morbidity ICD-10 codes will also help you with Chronic Care Management patient eligibility.

For 2020 there are more than 9,700 ICD-10-CM codes that map to one or more of the 86 HCC codes included in the 2020 CMS-HCC Risk Adjustment Model (Version 24).  While the number of HCC and ICD-10 codes involved sounds ominous to master, we can show you how to implement small workflow improvements that will generate near term clinical and financial rewards for your health system or medical group.

We can help your team start working towards more comprehensive ICD-10 coding that will enhance reimbursement for Original Medicare (OM) patients and Medicare Advantage (MA) patients.  Our consulting and training process is flexible and available for small or large groups.  The training will easily pay for itself in the near term.