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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 Coronary Artery Disease Hierarchy
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f2-hcfr-25-4-119: Hierarchical Condition Categories Coronary Artery Disease Hierarchy

Mentions: Hierarchies are imposed among related CCs, so that a person is only coded for the most severe manifestation among related diseases. For example (Figure 2), ICD-9-CM Ischemic Heart Disease codes are organized in the Coronary Artery Disease hierarchy, consisting of 4 CCs arranged in descending order of clinical severity and cost, from CC 81 Acute Myocardial Infarction to CC 84 Coronary Athlerosclerosis/Other Chronic Ischemic Heart Disease. A person with an ICD-9-CM code in CC 81 is excluded from being coded in CCs 82, 83, or 84 even if codes that group into those categories were also present. Similarly, a person with ICD-9-CM codes that group into both CC 82 Unstable Angina and Other Acute Ischemic Heart Disease, and CC 83 Angina Pectoris/Old Myocardial Infarction is coded for CC 82, but not CC 83. After imposing hierarchies, CCs become Hierarchical Condition Categories, or HCCs.5


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 Coronary Artery Disease Hierarchy
© Copyright Policy
Related In: Results  -  Collection

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

f2-hcfr-25-4-119: Hierarchical Condition Categories Coronary Artery Disease Hierarchy
Mentions: Hierarchies are imposed among related CCs, so that a person is only coded for the most severe manifestation among related diseases. For example (Figure 2), ICD-9-CM Ischemic Heart Disease codes are organized in the Coronary Artery Disease hierarchy, consisting of 4 CCs arranged in descending order of clinical severity and cost, from CC 81 Acute Myocardial Infarction to CC 84 Coronary Athlerosclerosis/Other Chronic Ischemic Heart Disease. A person with an ICD-9-CM code in CC 81 is excluded from being coded in CCs 82, 83, or 84 even if codes that group into those categories were also present. Similarly, a person with ICD-9-CM codes that group into both CC 82 Unstable Angina and Other Acute Ischemic Heart Disease, and CC 83 Angina Pectoris/Old Myocardial Infarction is coded for CC 82, but not CC 83. After imposing hierarchies, CCs become Hierarchical Condition Categories, or HCCs.5

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