Diagnosis Coding For Risk Adjustment – Are You Ready (AAFP)

The AAFP is a great first-stop for information on Risk Adjustment and HCC Diagnosis Coding. And although this article is a few years old (2018), their take on HCC Diagnosis Coding for Risk Adjustment is both unique and extremely helpful.

First, they lay out what it is and how it works. Then they tie it in with IDC-10 codes and HCC coding, to paint—with a broad brush—the full picture of what a practice will need to know, do and master to step into a risk adjustment payment model.





  1. Mapping ICD-10 codes to Hierarchical Condition Category (HCC) codes determines the severity of illness.
  2. Risk-adjustment factors heavily into new payment models.
  3. Physicians should report any diagnosis codes associated with chronic conditions that affect treatment choices, not just the diagnosis codes that describe why a patient came in .
  4. Physicians should comprehensively code chronic conditions at annual visits, as RAF (patient risk) scores reset every year.


Diagnosis Coding for Risk Adjustment




First it may be helpful to briefly review the connection between coding, risk adjustment, and payment. Risk-adjustment models assign each patient a risk score based on demographics and health status. Demographic variables may include age, gender, dual Medicare/Medicaid eligibility, whether the patient lives at home or in an institution, and whether the patient has end-stage renal disease. Health status is based on the diagnosis codes submitted on inpatient, outpatient, and professional claims in a calendar year. Certain diagnosis codes map to disease groups (HCCs). Demographics and HCCs are weighted and used to calculate a risk-adjustment factor (RAF) score. – AAFP


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The author then compiled a series of examples of HCC coding options, and how to determine which codes to use. Full list of examples here.



Family physicians can increase the accuracy of risk-adjustment scoring by focusing on capturing diagnosis codes for the conditions they see frequently. Electronic health record (EHR) systems can help by identifying diagnosis codes that carry an HCC weight, but most do not. A related article in this issue includes a reference tool that physicians can use to keep HCC codes and RAF scoring in mind when selecting diagnosis codes.





Link: https://www.aafp.org/fpm/2018/0300/p21.html




White Paper: Planning Ahead For Strict HCC Compliance Protocols
Key Findings From 400 RADV Audits, 2011-2021

HCC Quick Start Guide

Additional HCC Coding resources from The AAFP: https://www.aafp.org/fpm/2018/0300/fpm20180300p26-rt1.pdf

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