Certified Risk Adjustment Coder (CRC)

Which code set is primarily used for HCC coding?

1. CPT

2. HCPCS Level II

3. ICD-10-CM

4. ICD-10-PCS

The correct answer is: ICD-10-CM

The primary code set used for HCC (Hierarchical Condition Category) coding is ICD-10-CM. This coding system includes diagnosis codes that capture patient conditions and comorbidities, which are essential for risk adjustment in Medicare Advantage programs. HCC coding specifically relies on the accuracy of the ICD-10-CM codes to represent the complexity and severity of the patient's health status. ICD-10-CM codes are utilized to indicate the presence of specific health conditions that affect the risk adjustment process, which ultimately impacts reimbursement rates for health plans. Each condition corresponds to an HCC, and the health status of patients is assessed through these codes. Proper documentation and coding of the conditions lead to accurate risk scores that reflect resource needs and predict future healthcare expenditures. Other code sets, such as CPT, are focused on procedures and services rendered, while HCPCS Level II includes codes for non-physician services, supplies, and equipment. ICD-10-PCS, on the other hand, is primarily used for inpatient procedure coding rather than diagnosis coding. This highlights the unique role of ICD-10-CM in the HCC framework.