Certified Risk Adjustment Coder (CRC)

How are HCCs categorized?

1. A. Type of complication

2. B. Diagnosis groups

3. C. Organ systems

4. D. Age group

The correct answer is: B. Diagnosis groups

The categorization of Hierarchical Condition Categories (HCCs) is primarily based on diagnosis groups. This system organizes a variety of medical diagnoses into categories that reflect the severity and complexity of a patient's health status. Each HCC is linked to specific clinical conditions that have a significant impact on predicting health care costs and resource utilization. By grouping these conditions together, healthcare providers and payers can better assess risk, allocate resources effectively, and ensure that patient care is managed according to the complexities of their diagnoses. This categorization also facilitates the Risk Adjustment Model, which is crucial for programs like Medicare, as it aims to adjust payments to health plans based on the health status of enrollees. Other options, such as complication types, organ systems, or age groups, do not reflect the structured framework of HCCs and their purpose within risk adjustment strategies. Thus, while complications may arise from diagnoses, and age can impact health outcomes, HCCs are fundamentally about classifying diagnosis groups to enable better healthcare planning and financial management.