Transcription of Risk Adjustment Coding and HCC Guide
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Risk Adjustment Coding and HCC Guide
Power up your Adjustment Coding and HCC Guide2018 Optum360, LLCiContentsIntroduction .. 1 History and purpose of RAF ..1 Key Terms Definitions ..3 Acceptable provider types/SOS ..5 The provider s role ..6 Payment Methodology ..8 RAF Payment Timeline ..12 Coding and Documentation ..15 Explanation of impact of good documentation (table example).. 15 CMS 20 Coding Guidelines .. 44 Tools (MEAT/TAMPER) .. 48 Coding Scenarios/Examples/Teaching .. 59 Audits .. 79 Medicare Advantage Risk Adjustment Data Validation (RADV) .. 79 Health Effectiveness Data & Information Set (HEDIS) .. 87 Internal Care and Quality Improvement Audits ..91 Care and Quality Improvement Audits.
using the Hierarchical Condition Category (HCC)/risk adjustment model since 2004. The primary purpose of a risk adjustment model is to predict (on average) the future healthcare costs for specific consortiums enrolled in MA health plans. CMS is then able to provide capitation payments to these private health plans.
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