Is Your Diagnosis Coding Ready for Risk Adjustment?

Betsy Nicoletti


Fam Pract Manag. 2018;25(2):21-25. 

In This Article

Abstract and Introduction


As family physicians and their employers enter into risk-based contracts with payers and join accountable care organizations (ACOs), they are increasingly finding that payment depends on more than just the CPT and ICD-10 codes in their claims. Patient health status is one of several factors, including cost, utilization, and patient satisfaction, that are driving new models of physician payment. To quantify the severity of illness of patient panels, Hierarchical Condition Category (HCC) codes, long used by the Centers for Medicare & Medicaid Services to predict costs and set Medicare Advantage rates, are finding wider use.

Family physicians do not need to learn all the ins and outs of HCCs. However, understanding a few straightforward concepts and selecting ICD-10 codes that map to HCCs will contribute to a more accurate picture of patient health status and, in a growing number of practice arrangements, have a positive effect on payment.