Certified Risk Adjustment Coder (CRC)

In order for a code to be counted as part of the current CMS HCC model, which criterion must a diagnosis code meet?

1. The diagnosis is included in the CMS-Hierarchical Condition Category (CMS-HCC)

2. The diagnosis is a history code

3. The diagnosis has never been reported

4. The diagnosis is an acute condition

The correct answer is: The diagnosis is included in the CMS-Hierarchical Condition Category (CMS-HCC)

For a code to be counted as part of the current CMS HCC model, it is essential that the diagnosis is included in the CMS-Hierarchical Condition Category (CMS-HCC). The CMS-HCC model is designed to capture the complexities of patient health conditions, and it operates by utilizing specific diagnosis codes that have been determined to have a significant impact on expected healthcare costs. When a diagnosis code is part of the CMS-HCC, it means that the condition is recognized as contributing to the risk adjustment process, which accounts for the varying health statuses of patients in Medicare Advantage programs. Only those diagnoses listed in the official CMS-HCC categories are eligible for inclusion, ensuring that the model reflects relevant and quantifiable health issues within the patient population. This is crucial for risk adjustment, as it affects payment structures and healthcare resource allocations. The other options presented do not align with the criteria necessary for inclusion in the CMS-HCC model. While history codes may be relevant in certain contexts, they do not qualify under the criteria for risk adjustment if they are not included in the CMS-HCC. Acute conditions are significant in healthcare, but not all acute conditions are included in the CMS-HCC categories. Similarly, a diagnosis being reported or not is irrelevant if it does