2021 Risk Adjustment Coding and HCC Guide (eBook)

Optum360 | 2021 | Karen Krawzik



CALL 1-800-464-3649, Option 1

Item #: EHCCA21
ISBN: 9781622545391
Available: Dec 2020


The Risk Adjustment Coding and HCC Guide brings together hard-to-find information about risk adjustment (RA) coding and hierarchical condition categories (HCCs) in a new, comprehensive resource that explains this complex reimbursement methodology. Now your organization will have a guide that provides both the “big picture” and the fine detail needed to document, code and report essential information so that accurate risk levels are assigned and appropriate reimbursement received.

Originally developed for use by Medicare Advantage (MA) plans, HCCs are now used in a variety of value-based reimbursement (VBR) programs. Our new guide helps you navigate the shift from a fee-for-service environment to VBR and provides the tools necessary to ensure risk levels and resources are aligned.
  • Optum360 Edge — Understand risk adjustment coding and HCCs. Three types of HCCs covered under Medicare, CMS-HCC, Rx-HCC and ESRD/PACE-HCC are explained. HSS-HCCs used for commercial plans and VBR programs are also explored.
  • Optum360 Edge — Learn which demographic factors and conditions impact risk. Discover the role chronic conditions play in overall risk adjustment, how the risk adjustment factor (RAF) score is calculated, and how the cumulative RAF score for covered beneficiaries drives payments to health plans.
  • Optum360 Edge — Understand the provider’s role. Documentation and coding are the basis for delineating health status and calculating risk. Use the clinical documentation improvement tips to increase coding specificity which will translate into accurate RAF scores.
  • Optum360 Edge — Calculate RAF scores. Use the HCC tables to identify conditions that impact health status and cost of care. Calculate RAF scores for your patients to quantify risk.

Karen Krawzik, RHIT, CCS, AHIMA-approved ICD-10-CM/PCS Trainer

Ms. Krawzik has expertise in ICD-10-CM, ICD-9-CM, CPT®/HCPCS, DRG and data quality and analytics, with more than 30 years’ experience coding in multiple settings, including inpatient, observation, ambulatory surgery, ancillary and emergency room. She has served as a DRG analyst and auditor of commercial and government payer claims, as a contract administrator, and worked on a team providing enterprise-wide conversion of the ICD-9-CM code set to ICD-10. More recently, she has been developing print and electronic content related to ICD-10-CM and ICD-10-PCS coding systems, MS-DRGs and HCCs. Ms. Krawzik is credentialed by the American Health Information Management Association (AHIMA) as a Registered Health Information Technician (RHIT) and a Certified Coding Specialist (CCS) and is an AHIMA-approved ICD-10-CM/PCS trainer. She is an active member of AHIMA and the Missouri Health Information Management Association.

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