Risk Adjusted Coding - Overview Course

Description

This course offers a foundational look at risk adjustment and Hierarchical Condition Categories (HCCs), the methodology behind Medicare Advantage payments. Learners will explore how chronic conditions impact risk scores, how RAF scores are calculated, and why complete, accurate documentation is critical for capturing HCCs. Ideal for coders new to risk adjustment or seeking a refresher, this course breaks down key concepts like disease hierarchies, condition coefficients, and the role of M.E.A.T. criteria in supporting compliant coding.

Included Lessons:

What is Risk Adjustment?
Risk Adjustment and HCCs
Calculating the Risk Adjustment Factor Score
ICD-10-CM Coding for HCCs
Take Aways

Key Takeaways

Understanding of Risk Adjustment Models: Clear knowledge of how risk adjustment works, why it exists, and its impact on reimbursement—particularly under Medicare Advantage plans.
Familiarity with HCCs: Insight into how diagnoses map to Hierarchical Condition Categories and which conditions are most commonly missed.
RAF Score Components: A working understanding of how Risk Adjustment Factor (RAF) scores are calculated using HCCs, demographics, disease interactions, and other variables.
Hierarchies and Coefficients: Knowledge of how disease hierarchies and constrained coefficients influence scoring and prevent inflation.
Documentation Best Practices: Practical guidance on applying M.E.A.T. (Monitor, Evaluate, Assess, Treat) criteria to ensure documentation supports HCC coding.
Coding Accuracy: A deeper awareness of how missed or improperly coded chronic conditions can negatively affect both reimbursement and care planning.
Annual Review Requirements: An understanding that diagnoses must be captured at least once each calendar year for continued inclusion in risk scores.
Cross-setting Application: Recognition that documentation from any care setting (not just one encounter) may be used to validate chronic condition coding.

What is risk adjustment, and why should coders care?

Risk adjustment is a payment model used to predict healthcare costs based on patient conditions. Coders play a key role by ensuring that diagnoses are accurately captured to reflect a patient’s health status, which directly impacts reimbursement.

What are HCCs, and how are they used in coding?

Hierarchical Condition Categories (HCCs) are diagnosis groupings used in risk adjustment to assign value to chronic and severe conditions. Coders need to understand which diagnoses map to HCCs to support accurate reporting and appropriate payment.

What is a RAF score?

A Risk Adjustment Factor (RAF) score reflects the predicted cost of care for a patient based on their conditions and demographics. Coders contribute to accurate RAF scores by coding all reportable conditions supported by documentation.

About our Medical Coding Courses

HIAlearn, powered by Health Information Associates (HIA)—a leader in medical coding and auditing for more than three decades—offers a comprehensive online education platform for medical coders. With a catalog of over 200 medical coding courses accepted by the American Health Information Management Association (AHIMA) for Continuing Education Units (CEUs) and a selection approved by the American Academy of Professional Coders (AAPC), HIAlearn caters to both beginners and experienced medical coders seeking to enhance their skills. The platform provides an array of training plans tailored to meet individual learning needs, from mastering challenging coding procedures to understanding broad conceptual frameworks within the coding world. Courses are available across various coding types including CPT, E/M, ICD-10-CM, ICD-10-PCS, and are designed to cater to different coder levels and coding specialties such as inpatient, outpatient, profee, and CDI. Additionally, HIAlearn offers a Coding Updates bundle to ensure coders are up-to-date with the annual changes in ICD-10-CM, ICD-10-PCS, CPT, and IPPS. Beyond individual learning, HIAlearn supports organizations with group discounts, promoting enhanced coding accuracy, efficiency, and compliance across teams.