Problem Statement

HCC coding is how CMS and HHS estimate the medical complexity of a patient over a year. Each HCC has a Risk Adjustment Factor (RAF), which influences how much a health plan is paid for that patient. Accurate HCC coding ensures that chronic conditions are captured in the right year, so the plan receives the correct RAF score and payment. If an HCC is missed or coded incorrectly, the RAF score drops, reducing reimbursement. The HCC modifier signals to the risk adjustment system that the code is part of a HCC, so it will be included in the RAF calculation.

Automation Solution

This automation identifies qualifying diagnoses for risk adjustment, adds Hierarchical Condition Category (HCC) modifiers to claims, and submits them to payers to optimize value-based care reimbursement.