HCC Blog by Caridad

 CMS RxHCC can be found on this document which is the same document as the mapping. If you are interested, the corresponding weights are found here: https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Final-2021-Benefit-Year-Final-HHS-Risk-Adjustment-Model-Coefficients.pdf Page 12

 CMS.gov Internet Only Manuals Medicare Managed Care Manual Chapter 7 contains information on Risk Adjustment, 75 page document In 2021, the current manual is dated:   (Rev. 118, 09-19-14) https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019326

The HCC model and corresponding diagnosis code can be found on this pdf from CMS.  (Includes ICD-10 codes valid in FY2020 or FY2021, effective 1/1/21.) Medicare > Medicare Advantage Rates & Statistics > Risk Adjustment > 2022 Model Software ICD-10 Mappings

Disease coefficient values for calendar year 2021 can be found on these pages in the link below: Table VI-1. Alternative Payment Condition Count (APCC)      page 74 Disease Coefficients                                                           page 75 Disease Interactions                                                            page 79 Payment HCC Counts                                                       page 80 https://www.cms.gov/files/document/2021-announceme...

 Acceptable Physician Specialty Types for 2021 https://www.hhs.gov/guidance/document/2021-acceptable-physician-specialty-types

From the Department of Justice, Office of Public Affairs News dated Friday, July 30, 2021 The article states allegations against Kaiser on submission of HCC diagnoses: "Medicare requires that, for outpatient medical encounters, MA Plans submit diagnoses to CMS only for conditions that required or affected patient care, treatment or management during an in-person encounter in the service year. In order to increase its Medicare reimbursements, Kaiser allegedly pressured its physicians to create addenda to medical records after the patient encounter, often months or over a year later, to add risk-adjusting diagnoses that patients did not actually have and/or were not actually considered or addressed during the encounter, in violation of Medicare requirements.      The lawsuits were filed under the qui tam, or whistleblower, provisions of the False Claims Act" It will be interesting to follow this story and see how it turns out. https://www.justice.gov/opa/ pr/governme...

Thanks to Sheri Poe Bernard’s post on LinkedIn, here is a link to downloading all the ICD-10-CM codes and guidelines from CMS.  These are PDFs that can be downloaded to your desktop and searched using ‘Control F’. https://www.cdc.gov/nchs/icd/icd10cm_browsertool.htm   ICD-10-CM Browser Tool:              https://icd10cmtool.cdc.gov/ Once on this page, from the ‘Fiscal Year’ drop down menu, chose the year you want to view and there is a place to ‘Search for all term(s).   Over on the right side of the screen, there is a blue link where you can see ‘Guidelines’ and enter the exact code to search for.   Information includes: FY 2021 – includes Jan 2021 Addenda FY 2020 – includes Apr 2020 addenda FY 2019 – Oct 1 2018 FY 2018 – Oct 1 2017   Help guide:   https://icd10cmtool.cdc.gov/static/ICD-10-CM-Web-Help.pdf     Fun Facts: The National Center for Health Statistics ...