Risk Adjustment Coding and HCC Guide 2025

The Risk Adjustment Coding and HCC Guide 2025 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 the “big picture” and the fine detail needed to document, code, and report essential information to ensure 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. This 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.

Exclusive Optum Edge features found in this Optum360 risk adjustment coding guide:

• Optum Edge — Understand risk adjustment coding and HCCs.. Explanations provided on the three types of HCCs covered under Medicare, CMS-HCC, Rx-HCC, and ESRD/PACE-HCC. HSS-HCCs used for commercial plans and VBR programs are also explored.
• Optum Edge — Easy-to-use tables of HCCs. RxHCC and CMS-HCC Model risk adjustment tables are included.
• Optum Edge — Calculate RAF scores. Use the HCC tables to identify conditions impacting health status and cost of care. Calculate RAF scores for your patients to quantify risk.
• Optum Edge — Understand risk adjustment coding and HCCs. Explanations provided on the three types of HCCs covered under Medicare, CMS-HCC, Rx-HCC, and ESRD/PACE-HCC. HSS-HCCs used for commercial plans and VBR programs are also explored.
• Optum 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.
• Optum 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, translating into accurate RAF scores.

Additional features and benefits of Risk Adjustment Coding and HCC Guide include:

• Access to data files online. The CMS-HCC and HSS-HCC data files are provided on the Optum Product Update page on Optum’s website.
• User friendly format. New updated format provides the same great information in an easier to read format.