I am currently in the process of getting my CRC, and I work daily with HCC and Risk Adjustment. Even though Risk Adjustment started with Medicare Advantage in 2004, a lot of providers and even health plans are not really taking full advantage of the program. Any provider practices are always trying to maximize their reimbursement and income potential, and Risk Adjustment is for many practices and health plans, an untapped resource. Here is the “low-down”:

Pros:

• Can result in significant reimbursement to the practice and/or health plan if done correctly.
• Appears to be a growing field/area within coding.
• Uses same ICD-10 coding guidelines, with HCC specific guidelines. Build upon what you already know for ICD-10.
• A great way to take your coding career to the next level.

Cons:

• Main focus is on ICD-10 codes, not CPT/HCPCS. This could be a concern if you are a newer coder and you still need to be more well-rounded.
• Risk Adjustment/HCC coding is considered a sub specialty of coding, and has little to do with other areas of coding.
• Because there is that significant reimbursement potential, CMS is also ready to not just recoup wrongful monies, but also impose significant fines and more on failed audits.
• Although new coders can do HCC coding, and the CRC course is designed for new coders (no CPC requirement), I would personally recommend having at least several coding years under your belt before diving into HCC coding full time.

On a provider group level, HCC can generate that much needed reimbursement/income to widen your margin enough for sustainable growth. Especially if you have a shared risk contract with your contracted health plan.

On a health plan level, HCC is a significant factor to pay provider claims, reduce or stabilize member premiums, and more.

My sources tell me that not only is Risk Adjustment here to stay, but it is only getting bigger. Risk Adjustment started in 1997 with Medicaid, 2004 Medicare Advantage and was most recently expanded into the ACA Commercial market in 2014.

Let me know if you have any other questions.