The premium that Centers for Medicare & Medicaid Services (CMS) compensates Medicare Advantage Plans is based on underlying health conditions of Medicare Advantage enrollees. These conditions are determined by a risk adjustment factor which is calculated using the enrollee’s age, sex, disability, Medicaid, and diagnosis codes. The conditions are identified through ICD-10 codes submitted on claims which are mapped to Hierarchical Condition Category (HCC) codes.

As discussed in a prior blog post by Dr. James Matera, HCC risk adjustment and coding is a payment model that uses a patient’s health status and demographic information to calculate a risk score in order to establish baseline for how much it would cost to provide care to that patient. The higher the risk score, the more at risk the patient, and the more the health plan is compensated annually for providing care to that patient. This also impacts future payments.

CMS requires the documentation of the condition at least once per year, with the year restarting every January 1. All patients are considered “healthy” until the diagnosis codes are reported on claims for that year.

Overall risk is assessed by the accumulation of total codes, even if unrelated, and/or with disease and overlapping conditions (such as diabetes plus congestive heart failure vs. diabetes alone). For more reliable risk scores, it’s important to document how sick patients really are, and any complications (such as renal disease or DM with nephropathy). Some diagnoses, like hypertension, carry no weight and are not predictive. However, when paired with vascular disease, they have a higher weight.

Documentation is key for reliable risk scores. It’s critical to list the diagnoses as well as any clinical findings and supportive details. If you document the exam as normal, but you list several diagnoses to drive complexity, this is not favorable. Rather, document clinical findings to the highest level of specificity.

Avoid phrases like “without complication,” “unspecified,” and “history of …” if possible. Instead, be more specific. For example, if there are any resulting issues from a history of stroke, use “stroke with sequelae” or “post-stroke syndrome.”

Include cancers, even when in remission. Also include conditions like anemias, dysplastic syndrome, COPD, obesity, IBD, and hepatitis C.

Remember, the Benchmark HCC Score is 1. Below this is lower risk and above this is higher risk. For example, if a patient has an HCC Score of 1.10, the patient is expected to have 10% higher healthcare expenses over the next 12 months compared to the average patient (HCC=1).


Common Diagnoses

DM1 w/kidney complications
DM2 w/kidney complications
CKD Stage 4, 5 and ESRD (stages 1-3 no risk)N18.4-N18.60.237
DM1 w/neuro, circulatory, other specified complications
DM2 w/neuro, circulatory, other specified complications
E10.40, etc.
E11.40, etc.
DM1 w/hyperglycemia, hypoglycemia
DM2 w/hyperglycemia, hypoglycemia
Hypertensive Heart Disease w/heart failureI11.00.323
Hypertensive cause of specific heart failure (LV, biventricular, etc.)I50.1, I50,820.323
Acute embolic stroke (CVA) w/infarctionI63.400.263
Previous CVA with residual hemiplegiaI69.3590.538
Morbid ObesityE66.010.273
Protein-Calorie MalnutritionE44.00.545
Alcohol Dependence in remissionF10.210.383
Opioid Dependence, uncomplicatedF11.200.383
Inhalant abuse with intoxication, uncomplicatedF18.1200.383
Major Depression (single, recurrent episodes, remission), mild to severeF32.0-F33.90.395

– Robert Pedowitz, DO, Chairman, CPC and IT Committee and CHP Board Member