Certified Risk Adjustment Coder (CRC)

The Hierarchical Condition Categories (HCC) model is most commonly used by Medicare for risk adjustment. This model assigns a risk score to beneficiaries based on their diagnoses and demographic information, which helps in predicting future healthcare expenditures. The HCC model allows Medicare Advantage plans to receive appropriate funding based on the health status and needs of their enrollees, ensuring that plans serving sicker beneficiaries are adequately compensated. The HCC model is structured to reflect the severity of a patient's health conditions and the complexity of their needs. By using this comprehensive approach, it is designed to incentivize appropriate care management and improve patient outcomes. Other models mentioned, such as the Chronic Illness and Disability Payment System (CDPS) and blended models, may be used in different contexts or for different populations, but within the realm of Medicare, HCC is the primary model applied. Fee-for-service is a payment model rather than a risk adjustment model, emphasizing the importance of understanding how various systems interact within healthcare financing and coding compliance.