AB202019 - Understanding HCC Risk Adjustment Model

Assignment Task

Overview

Risk adjustment has become a major component of prospective payment systems. It is used extensively in value-based purchasing plans. It is important for HIM professionals to understand the mechanics of risk adjustment. This assignment explores the CMS HCC model that is used for Medicare Part C Medicare Advantage (managed care). In this exercise, V23 of CMS-HCC Model is utilized. 

 INSTRUCTIONS:  

1. Review tabs HCC Titles and Risk Scores and CMS HCC Model Codes.

2. Complete problems 1 through 4 located on the Problems tab.

3. Review the clinical scenario.

• Examine the codes reported for each scenario.
• Use tabs HCC Titles and Risk Scores and CMS HCC Model Codes to complete the grid for each problem. 
• Answer the question presented below the grid: Is this patient’s risk score higher or lower than the average Medicare patient? The risk score for an average Medicare beneficiary is 1.0.

Complete the following contemplation questions:

1. Which condition were you surprised was not included in the CMS HCC risk adjustment model?

2. Which condition were you surprised was included in the CMS HCC risk adjustment model?

3. Which condition’s risk score was lower than expected?

4. Which condition’s risk score was higher than expected?

If you had to explain this adjustment model to a family member new to Medicare Advantage, how would you explain it using non-technical terms?

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