Navigating Challenges in HCC Coding and Risk Adjustment

HCC coding processes while not designed to be complex, may not be immediately apparent, making them tedious and time-consuming. Despite its inherent difficulty, the main goal is to provide an accurate and complete overview of each member’s risk profile with the goal of better understanding their health state and being able to predict the cost of care.

Every year, the Centers for Medicare and Medicaid Services (CMS) mandates that providers identify all eligible conditions. Insufficient documentation and non-specific diagnosis have a negative influence on reimbursement. More accurate HCC risk adjustment coding and appropriate remuneration for excellent care can be achieved when healthcare organizations strengthen their EMR tools, data, analytics, and education programs for patients with chronic conditions.

As the number of medicare advantage beneficiaries continues to rise yearly, it becomes even more important for providers to assign patients appropriate HCC codes. Better HCC risk coding can facilitate more wholesome care for patients and fair reimbursement for healthcare providers.

Some of the main points of the HCC system and risk adjustment processes include:

  • Each year, CMS requires that a patient has contact with an APRN, PA, or physician.
  • The diagnosis can only be supported if the documentation is accurate. 
  • Only some ICD 10 codes have HCC Value assigned. For example, the table below includes a few ICD 10 codes with CMS HCC value assigned vs. no value assigned:
ICD 10 CMS HCC value assigned ICD 10 No CMS HCC value assigned
J69.0 Aspiration Pneumonia J18.9 Pneumonia
N18.4 CKD 4 N28.9 Renal Insufficiency
I48.91 Atrial Fibrillation I49.9 Arrhythmia
F32.0 Major depression, single, mild. F32.9 Depression
G20 Parkinson R25.1 Tremor


  • It might be difficult to decipher some HCC codes. It is possible that doctors will seek assistance in making decisions.
  • Many Medicare contracts are affected by the complexity and severity of the population.

Furthermore, The conventional HCC risk adjustment coding method is time-consuming and inefficient, often stifling operations. Medical coders go through massive amounts of medical records to achieve more accurate risk rankings. The lengthy and costly process may annoy healthcare workers, leading to human error (such as missing HCC risk codes) that can cost a healthcare provider millions. Traditional coding inefficiencies cost healthcare organizations 20-30% of annual revenue, according to IDC. Manual processes will become harder to sustain as coding approaches become more advanced, which is why a lot of Healthcare providers are looking for technology to help support these processes.

In our previous article, we talked about how accurate data management is a key step in making improvements in the HCC coding sector along with the development of a task-specific team to improve patient care and delivery. In addition to considering a task-specific team assigned, we also suggest looking into smart HCC Coding and risk adjustment technology, this can help your teams achieve more accurate results and save time. Check out Inferscience’s HCC Assistant to learn more about HCC coding technology that is EHR integrated.



  • U.S department of Health & Human Services guidance document on risk adjustment;
  • Centre for Medicare & Medicaid services guidance on HCC coding & risk adjustment;
  • International Classification of Disease (ICD-10)- CM codes;
  • American Academy of Family Physicians (AAFP); HCC Coding, Risk Adjustment, and Physician Income: What You Need to Know;
  • Diagnosis Coding for Value-Based Payment: A Quick Reference Tool;
  • Understanding and Improving Risk Adjustment in Team-Based Care;


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