Glossary · Programs
Glossary · ProgramsHCC (Hierarchical Condition Category)
The CMS risk-adjustment coding methodology used to predict healthcare costs for Medicare Advantage and ACO populations. Higher RAF (Risk Adjustment Factor) scores reflect more complex patients and higher payments.
Definition
HCC (Hierarchical Condition Category).
The CMS risk-adjustment coding methodology used to predict healthcare costs for Medicare Advantage and ACO populations. Higher RAF (Risk Adjustment Factor) scores reflect more complex patients and higher payments.
Sources
Primary references for this entry.
- CMS Medicare Advantage Risk Adjustment Model.
- AAPC HCC Coding Guide.
Related terms
Other terms in Programs.
- Programs
Annual Wellness Visit (AWV)
A Medicare preventive visit (G0438 initial, G0439 subsequent) for personalized prevention plans. Distinct from a routine physical and reimbursable separately when documented per CMS requirements.
Open entry - Programs
Chronic Care Management (CCM)
A Medicare-reimbursable program (CPT 99490, 99439, 99491, 99437) for non-face-to-face management of patients with two or more chronic conditions expected to last at least 12 months.
Open entry - Programs
PPS Encounter (Prospective Payment System)
The Medicare and state Medicaid payment methodology for FQHCs and RHCs that pays a fixed encounter rate per qualifying patient visit, regardless of services rendered during the visit.
Open entry - Programs
Remote Patient Monitoring (RPM)
A Medicare-reimbursable service (CPT 99453, 99454, 99457, 99458) for collecting and reviewing physiologic data transmitted by patient devices outside a clinical setting.
Open entry - Programs
Risk Adjustment
The methodology that adjusts payments to plans and providers based on the predicted health-care costs of their patient population, typically using HCC coding and a Risk Adjustment Factor (RAF) score.
Open entry - Programs
Transitional Care Management (TCM)
A Medicare service (CPT 99495 moderate complexity, 99496 high complexity) for managing a patient's transition from inpatient or observation back to community within 30 days of discharge.
Open entry
Frequently asked
About HCC (Hierarchical Condition Category).
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