Glossary · Programs
Glossary · ProgramsRisk 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.
Definition
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.
Sources
Primary references for this entry.
- CMS Medicare Advantage Risk Adjustment Model.
- CMS HHS Risk Adjustment Methodology.
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
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.
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
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
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