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Risk adjustment of Medicare capitation payments using the CMS-HCC model.

Pope GC, Kautter J, Ellis RP, Ash AS, Ayanian JZ, Lezzoni LI, Ingber MJ, Levy JM, Robst J - Health Care Financ Rev (2004)

Bottom Line: This article describes the CMS hierarchical condition categories (HCC) model implemented in 2004 to adjust Medicare capitation payments to private health care plans for the health expenditure risk of their enrollees.We explain the model's principles, elements, organization, calibration, and performance.Modifications to reduce plan data reporting burden and adaptations for disabled, institutionalized, newly enrolled, and secondary payer subpopulations are discussed.

View Article: PubMed Central - PubMed

Affiliation: RTI International, Waltham, MA 02452, USA. gpope@rti.org

ABSTRACT
This article describes the CMS hierarchical condition categories (HCC) model implemented in 2004 to adjust Medicare capitation payments to private health care plans for the health expenditure risk of their enrollees. We explain the model's principles, elements, organization, calibration, and performance. Modifications to reduce plan data reporting burden and adaptations for disabled, institutionalized, newly enrolled, and secondary payer subpopulations are discussed.

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Hierarchical Condition Categories Aggregations of ICD-9-CM Codes
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f1-hcfr-25-4-119: Hierarchical Condition Categories Aggregations of ICD-9-CM Codes

Mentions: As shown in Figure 1, the HCC diagnostic classification system first classifies each of over 15,000 ICD-9-CM codes into 804 diagnostic groups, or DxGroups. Each ICD-9-CM code maps to exactly one DxGroup, which represents a well-specified medical condition, such as DxGroup 28.01 Acute Liver Disease. DxGroups are further aggregated into 189 Condition Categories, or CCs.4 CCs describe a broader set of similar diseases, generally organized into body systems, somewhat like ICD-9-CM major diagnostic categories. Although they are not as homogeneous as DxGroups, CCs are both clinically- and cost-similar. An example is CC 28 Acute Liver Failure/Disease that includes DxGroups 28.01 and 28.02 Viral Hepatitis, Acute or Unspecified, with Hepatic Coma.


Risk adjustment of Medicare capitation payments using the CMS-HCC model.

Pope GC, Kautter J, Ellis RP, Ash AS, Ayanian JZ, Lezzoni LI, Ingber MJ, Levy JM, Robst J - Health Care Financ Rev (2004)

Hierarchical Condition Categories Aggregations of ICD-9-CM Codes
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4194896&req=5

f1-hcfr-25-4-119: Hierarchical Condition Categories Aggregations of ICD-9-CM Codes
Mentions: As shown in Figure 1, the HCC diagnostic classification system first classifies each of over 15,000 ICD-9-CM codes into 804 diagnostic groups, or DxGroups. Each ICD-9-CM code maps to exactly one DxGroup, which represents a well-specified medical condition, such as DxGroup 28.01 Acute Liver Disease. DxGroups are further aggregated into 189 Condition Categories, or CCs.4 CCs describe a broader set of similar diseases, generally organized into body systems, somewhat like ICD-9-CM major diagnostic categories. Although they are not as homogeneous as DxGroups, CCs are both clinically- and cost-similar. An example is CC 28 Acute Liver Failure/Disease that includes DxGroups 28.01 and 28.02 Viral Hepatitis, Acute or Unspecified, with Hepatic Coma.

Bottom Line: This article describes the CMS hierarchical condition categories (HCC) model implemented in 2004 to adjust Medicare capitation payments to private health care plans for the health expenditure risk of their enrollees.We explain the model's principles, elements, organization, calibration, and performance.Modifications to reduce plan data reporting burden and adaptations for disabled, institutionalized, newly enrolled, and secondary payer subpopulations are discussed.

View Article: PubMed Central - PubMed

Affiliation: RTI International, Waltham, MA 02452, USA. gpope@rti.org

ABSTRACT
This article describes the CMS hierarchical condition categories (HCC) model implemented in 2004 to adjust Medicare capitation payments to private health care plans for the health expenditure risk of their enrollees. We explain the model's principles, elements, organization, calibration, and performance. Modifications to reduce plan data reporting burden and adaptations for disabled, institutionalized, newly enrolled, and secondary payer subpopulations are discussed.

Show MeSH
Related in: MedlinePlus