Risk Adjustment and HCC Coding: Getting Paid Accurately for Complexity
In risk-based contracts, documentation IS revenue. How Hierarchical Condition Categories and RAF scores drive accurate payment.
In Medicare Advantage and many value-based contracts, payment is risk-adjusted: sicker, more complex patients should fund more care. Hierarchical Condition Categories (HCCs) and the resulting Risk Adjustment Factor (RAF) translate documented conditions into payment.
The core discipline
- Capture and document all active chronic conditions every year
- Code to the highest appropriate specificity
- Support every diagnosis in the note (MEAT criteria)
- Reconcile suspected vs. documented conditions
Compliance matters
Risk adjustment is high-reward and high-scrutiny. Accurate, well-documented capture is the goal — never unsupported codes.
How Aethera helps
Aethera’s coders run HCC gap analysis and documentation support so your RAF reflects your true patient complexity — accurately and defensibly.
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