Certified Risk Adjustment Coder (CRC)

Which risk adjustment model incorporates a numeric value indicating high, medium, and low risk?

1. HCC

2. CDPS

3. ACA-HHS

4. Medicare Advantage

The correct answer is: HCC

The Hierarchical Condition Categories (HCC) risk adjustment model is designed to assign risk scores based on documented medical conditions of a patient. Each condition has a corresponding numeric value that reflects the expected healthcare costs associated with that condition, categorizing patients into high, medium, or low risk based on their calculated scores. The HCC model utilizes these categories to better predict healthcare expenses and resource utilization, allowing for more accurate adjustments in reimbursement rates for Medicare programs. This categorization is essential as it helps insurers and healthcare providers identify patients who may require more intensive medical management and support, thereby optimizing care delivery and resources. The HCC model specifically links the diagnosis coding, or ICD-10 codes, to the risk scores, ensuring that the financial implications of patient care are adequately accounted for. In contrast, the other models like CDPS, ACA-HHS, and Medicare Advantage do not utilize a straightforward numeric value system indicating high, medium, or low risk in the same manner as HCC does, thereby making HCC the most appropriate choice for this question.