Certified Risk Adjustment Coder (CRC)

What is the purpose for capturing diagnosis codes in an HCC model?

1. Determine the correct fee for service payment.

2. Determine the combined risk adjustment factor.

3. Determine the QPP bonus payment.

4. Determine the patient premium.

The correct answer is: Determine the combined risk adjustment factor.

Capturing diagnosis codes in a Hierarchical Condition Category (HCC) model serves the primary purpose of determining the combined risk adjustment factor. The HCC model uses these codes to reflect the health status of patients and quantify their risk, which is essential for accurately adjusting payments to healthcare plans based on the expected cost of providing care to enrollees. By coding specific diagnoses, healthcare providers can demonstrate the complexity and severity of a patient's conditions. This information is vital for the risk adjustment process, as it helps to ensure that plans receive appropriate financial reimbursement relative to the risk profile of their patient population. The combined risk adjustment factor then informs overall funding and resource allocation, ensuring that higher-risk patients are adequately compensated and that healthcare plans can deliver necessary care. This mechanism is particularly important because it addresses variations in patient health status, allowing for a more equitable comparison of plan performance. Therefore, capturing accurate and comprehensive diagnosis codes directly impacts the risk adjustment factor that ultimately influences financial reimbursements and supports the sustainability of health insurance models.