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Mips Tips Oct. 2018 - What Is HCC and How Does It Impact 10.16.18 Final
Mips Tips Oct. 2018 - What Is HCC and How Does It Impact 10.16.18 Final
Kidney Substance
Chronic kidney disease,
Abuse
stage 4 (CKD) HCC 137 Alcohol/Opioid
dependence HCC 55
What is RAF?
• Risk adjustment factor is a numeric value assigned by CMS to identify the health
status of a beneficiary/enrollee
• Risk adjustment score is determined by using a combination of demographic
information along with disease information to predict future healthcare cost for
enrollees
– Demographic
• Age, gender, Medicaid status, disability, geography, institutional living status
– Diseases
• Diagnoses submitted by providers
– PCPs, Specialists, Ancillaries, Hospitals, SNFs. PTs etc.
• CMS requires that a qualified health care provider identify all conditions that
may fall within an HCC at least once, each calendar year
– Risk scores reset each year
Interpreting the Risk Adjustment Factor
2017
MIPS Cost
2013 Category
Value Modifier
Program
2004
Developed
HCC and RAF: Essential in Today’s Payment Models
Characterizes Risk
This material was prepared by HealthInsight, the Medicare Quality Innovation Network-Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with
the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-
D1-18-80
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