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How do HCCs impact reimbursement? HCCs directly impact the amount of money received by healthcare organizations from the largest single payer in healthcare, CMS. Patients with high HCCs are expected to require more intensive medical treatment verses those enrollees who have low HCCs.

The CMS-HCC risk score for a beneficiary is the sum of the score or weight attributed to each of the demographic factors and HCCs within the model. The CMS-HCC model is normalized to 1.0. Beneficiaries would be considered relatively healthy, and therefore less costly, with a risk score less than 1.0.

Affects Reimbursement: Improper coding leads to improper billing, which can directly impact a clinic's bottom line. Incorrectly down-coding a major procedure as something less accurate will result in lower reimbursements.

The HCCs, together with demographic and program information, are used to determine a patient's risk adjustment score. These RAF scores are then used to predict next year's (prospective risk adjustment) or this year's expenditures.

Medicare Risk Adjustment (MRA) refers to the process of adjusting Medicare patient risk scores ing to diagnostic codes assigned to them by healthcare professionals. Risk adjustment is critical so that health plans are adequately funded ing to patient needs.

For 2023, the CMS-HCC ESRD model will include new enrollee, continuing enrollee, functioning graft, and long term institutional (LTI) segments.

The Role of Hospital Coding in Revenue Cycle Management Hospital billing and coding serve as the backbone of revenue cycle management. Medical coding translates medical services, diagnoses, procedures, and equipment into a set of universal medical alphanumeric codes used for claims submission and reimbursement.

Each HCC is mapped to an ICD-10-CM code. Along with demographic factors such as age and gender, insurance companies use HCC coding to assign patients a risk adjustment factor (RAF) score. Using algorithms, insurance companies can use a patient's RAF score to predict costs.