Certified Risk Adjustment Coder (CRC)

Do the HCC category hierarchies play a role in which medical record to submit for a RADV?

1. A. No, there are no benefits in taking hierarchies into consideration.

2. B. No, CMS will treat all diagnosis with the same financial weight.

3. C. Yes, CMS will accept a lower or higher HCC to validate an HCC within the same category.

4. D. Yes, there can be a financial gain by submitting a higher hierarchy HCC.

The correct answer is: C. Yes, CMS will accept a lower or higher HCC to validate an HCC within the same category.

The correct answer highlights the importance of HCC (Hierarchical Condition Category) hierarchies in the context of RADV (Risk Adjustment Data Validation). HCC hierarchies are essential as they determine how various diagnoses relate to one another for purposes of risk adjustment. Specifically, CMS allows for flexibility when validating submitted diagnoses; if a lower HCC is documented, it can still be validated as part of the same category even if a higher HCC was submitted. This means that the validation process isn’t strictly limited to the highest HCC; instead, it recognizes that various conditions can coexist and still be associated with a financial impact. Submitting a diagnosis that falls within the same HCC category but is of a different hierarchy can be beneficial for providers, as it allows them to demonstrate the complexity of patient conditions accurately. This is particularly important in cases where both the lower and higher HCCs accurately reflect the patient's health status, giving doctors a better chance of being reimbursed properly for the level of care they provide. In summary, understanding and utilizing HCC hierarchies effectively enhances a provider's ability to navigate RADV requirements and leads to accurate reimbursement based on validated diagnostic information.