HCCs and Risk Adjustment

I am working on the finishing touches on our Risk Adjustment Bootcamp, those of you that work in this arena what are the diagnoses or HCCs that you feel are frequently missed in provider documentation? Where are the missed opportunities?


  • I understand HCCs and risk adjustment but I have two questions that I can't get clear answers from researching the topic:

     1) Do HCCs only apply to Medicare Advantage and 2) How does capturing HCCs affect hospital payment.

  • Two great questions. There are several methodologies related to risk adjustment, the CMS-HCC methodology is but one of them. The CMS-HCC methodology is used for Medicare Advantage Payment as well as to assist with risk adjustment related to a number of quality measures such as 30 day mortality and readmissions. 

    Inpatient hospital care is reimbursed by CMS based on the DRG but payers can contract to pay for care based on a number of measures. (quality, length of stay, severity of illness etc). the Medicare Advantage Plans rely on provider documentation (both in the inpatient & outpatient setting) to determine the patient's risk score. This is one area where providers and payers must work together. 
  • I hope your recent Risk Adjustment Bootcamp went well.  I want to attend the Bootcamp and was wondering if any additional dates will be added in 2016?  Is Atlanta in October the next opportunity to attend?

    Julie Geiger BS, RN, CCDS

    Operational Lead Clinical Documentation Specialist

    Parkview Health

    11109 Parkview Plaza Drive

    Fort Wayne, IN 46845




  • Hello Julie, the class went really well. We had a great mix of experience in the room to include CDIS, coders and even a few coders who work for the payers. We have two courses scheduled- The Atlanta class in October and one in Las Vegas in November.

  • Great to hear and thank you for information on upcoming courses. 
  • Does anyone have any templates they are using for record review (HCCs) in the physician practices they would be will to share?
  • I have a question regarding HCC 58: MDD, Bipolar & Paranoid disorders.

     I am currently working with outpatient Physician practices for Risk Adjustment Documentation, and several physicians refuse to document or diagnose "Major Depressive Disorder" even if the patient meets the depression screening (PHQ 2/PHQ9) and is on active antidepressant. Diagnoses like "insomnia, anxiety disorder" becomes the diagnosis .  

     I've been told that "MDD diagnosis gets denied" and is not "accepted by their Billing vendor", because "only psychiatrists can diagnose MDD"

    I do not agree with the above statement, and is there an official guideline that I can refer to and present to the outpatient Family Practice physicians?

    Thanks,  Martha Padolina RN CCDS


  • I dont have an official guideline- MDD is a medical diagnosis. If the provider is ordering the medication to treat it they should be able to verify its presence. The screening tool is useful in establishing clinical indicators for query- but you also might wish to offer education to your providers concerning the diagnostic criteria. This criteria is well defined in the DSM 5.
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