🩺 Magical Knowledge of Risk Adjustment and Job-Ready Tips - A Little Uni & Friends Guide
A Legendary Bonus Quest, because clean claims and combo codes are our kind of glitter!
Hey there, magical coding Unicorns! 🦄✨
We’re thrilled to share a sparkling collaboration between three Risk Adjustment pros who joined forces on a mission of mentorship! What started as a project to build a presentation for new medical coders turned into a passion-fueled guide full of risk adjustment wisdom and job-ready gems. 🌟
🦄 New to Risk Adjustment? Or a seasoned codecaster slinging HCCs like spells? Either way, you’re in the right place.
This isn’t your average guide. It’s a magical mash-up of smart coding, chronic condition mastery, and job-ready tips to help you stand out in today’s fast-paced health info world.
✨ Think: combo codes, MEAT criteria, and real-world gems to help you shine in your role (or land your dream one).
Grab your enchanted highlighter. Let’s dive into the sparkly world of Risk Adjustment with confidence, clarity, and a little unicorn flair. 💼💫
🦄 Why Do We Care in Risk Adjustment Land, and What’s an HCC?
Welcome to the kingdom of coding, where every diagnosis tells a story, and some stories are worth a little extra gold. That’s where HCCs (Hierarchical Condition Categories) come in! These are special diagnosis codes that help predict how much care a patient might need throughout the year.
That’s part of the magical world of Risk Adjustment, a payment model used in Medicare Advantage, ACA plans, and other enchanted realms. It adjusts payments based on how complex the patient is, not just how many times they visit the doctor. Fair, right?
✨ In plain English?
HCCs = "Hey, this condition could cost more to manage. Let’s make sure the plan gets paid fairly!"
🧠✨ A Deeper Dive into HCCs
Hierarchical Condition Categories (HCCs) are groups of related ICD-10-CM codes that reflect serious, chronic, and high-impact health conditions. The more complex the condition, the more weight it carries in telling the patient's full story.
🦄 In Little Uni’s words:
HCCs group powerful diagnoses into mighty clusters of coding magic! The more complex the condition, the more sparkle it adds to the patient’s risk profile 💥
📌 Example: Diabetes with complications (👁️🦶💉) carries more weight than diabetes without complications, because more resources are needed to manage it.
💖 Value-Based Care: Quality Over Quantity
Now, let’s take a gallop through an even bigger idea:
🧠 Value-Based Care!
Unlike the old-school Fee-for-Service model (where providers get paid for each poke and prod), Value-Based Care (VBC) says: “Let’s pay for quality, not just quantity.” 🌟
Risk Adjustment is one shining path under the VBC rainbow, but there are others too:
🧺 Bundled payments (like a care package for surgery)
💰 Shared savings (teams get rewarded for smart care)
🧭 Accountable Care Organizations (magical maps for coordinated care)
In the realm of Value-Based Care (VBC), it’s not about how many patients you see 👥 - it’s about how well you care for them ❤️🩹
That’s where HCCs and RAF scores come in:
🔍 They help providers get paid fairly for treating medically complex patients
🏆 They ensure care teams are supported for the real-world needs they manage
💰 They guide payments that reflect quality, not just volume
✨ Code it right, support the care, and let the magic of value-based success unfold! 🧾🪄💫
So, the big picture?
Risk Adjustment supports Value-Based Care.
HCCs fuel Risk Adjustment.
And Value-Based Care is all about better care, better outcomes, and a better use of unicorn sparkle (okay, maybe resources).
📊 Know Your Models
They’re different creatures, so don’t assume one size fits all. Stay on top of model updates as they change periodically, about every couple of years. Some chronic conditions fall off with model changes, as well as new ones are added.
Different risk adjustment models include, but are not limited to:
HHS-HCC → for ACA Marketplace plans
CMS-HCC → for Medicare Advantage
V24 vs V28 → part of Medicare Advantage; Phasing in: 50% (2024), 100% (2025)
V24: broader mapping, more lenient coding
V28: stricter logic, more clinical precision
V28 = fewer codes count, combo codes matter more, quality > quantity
🔍 Focus Like a Pro(vider): What Really Matters in HCC/RA
📘 ICD-10-CM Accuracy
Focus on accurately capturing chronic conditions.
Start with the chronic all-stars, as they drive the risk, and they drive the reimbursement.:
Diabetes, CHF, CAD, CKD, COPD, HIV/AIDS, Major Depression, Cancer.
🪄 Combo Coding Tip:
Don’t code separately when a combo code does the job. Use combination codes when applicable to reflect linked conditions:
• E11.22 + N18.30 instead of E11.9 + N18.30
• I12.9* + N18.30 instead of I10* + N18.30
*Although not always chronic, Hypertension (HTN) becomes chronic when combo coded (as in HTN and CKD (I12.9) and/or CHF (I11.0).
It's like casting two spells with one wand! As in the example above, always capture the stage of CKD, even with a combo code.
🥩 MEAT Criteria
Every coded condition needs documentation that shows it’s:
Monitored, Evaluated, Assessed, or Treated.
(Yes, even combo codes need MEAT for both conditions.)
🚫Avoid These Mistakes
· Overcoding: Adding unsupported conditions.
· Undercoding: Missing out on high-value combo codes.
· No linkage: Forgetting to tie in labs, meds, or context = denial drama.
💡 Uni's Pro Tips for Maximum Sparkle
✨ Make a combo code cheat sheet for your top chronic faves
✨ Use OneNote or your favorite app to organize resources, examples, and audit feedback
✨ Use the Snipping Tool like a screenshot ninja, but always block PHI!!!
✨ AHA Coding Clinics - Coding Clinics are like spellbooks for coders, full of official wisdom to help you tackle the trickiest scenarios with confidence and clarity!
✨ Regularly review your ICD-10-CM Guidelines (the diagnosis Bible).
Here are just a few to start with:
Other and Unspecified codes: I.A.9
Excludes Notes: I.A.12
The “with” convention: I.A.15
Combo coding sections: I.B.9
CKD staging
Neoplasm rules
Borderline conditions
Abuse/neglect hierarchy
HIV vs AIDS
COPD vs Asthma vs Emphysema
🔎 Code Lookup & Encoder Tools
ICD10data.com - Fast, clear, combo code-friendly, applicable to (diagnosis synonyms)
FindACode.com - With RA indicators, smart search, NCCI Edits
Codify by AAPC - Full encoder with risk-adjustment insights
HCC Coder - Complete HCC Risk Adjustment Medical Coding Software
Optum Encoder - The ultimate coders toolkit: CPT, ICD-10-CM/PCS (including HCCs), ICD-9-CM, and HCPCS Level II online code look-up software offers fast, detailed search capabilities of over 20 volumes of procedure, service/supply, and diagnosis reference material and lay descriptions in real-time
📚 Resources from Uni’s Secret Scrolls
Here’s where I gallop to when I need clarity or inspiration:
AAPC - Webinars, articles, certification resources, etc.
CMS.gov - CMS HCC Model PDFs, Official ICD-10-CM Guidelines (link above), CMS ICD-10 Codes Resource Hub ← Bookmark this one! 🖱️📌
Sheri Poe Bernard’s book – Risk Adjustment Documentation & Coding
YouTube Channels for all things coding-related, not just RA (Coding YouTubers = real MVPs):
CCO
Contempo Coding
Coding with Blue
Medical Coding by Jen
AMCI Medical Coding Institute
Medical Coding with Legacy Education
Healthcare Inspired, LLC
HCC/RA Specific - What is HCC Coding, What is Risk Adjustment, RA resources - AAPC, RA Resources - CMS, RA Fundamentals - Medutrain Course
🌈 Final Sparkle: You’ve Got This!
Risk Adjustment coding isn’t just about codes; it’s about understanding the story the data tells. It's our job to make sure that every diagnosis reflects real care, real conditions, and real complexity.
So, study those combo codes, review those guidelines, and don’t forget:
You bring the magic to medical coding.
🏢✨ Job-Ready Tips & Project Work: Unicorn Edition!
So, you’re thinking about project-based coding work? Saddle up, superstar! Let’s trot through what that means in our magical coding world 🦄💼
🌟 Who’s Hiring the Herd?
Lots of great companies offer temp or contract work! Specifically, HCC coding is typically seasonal, but don’t fret! Some companies do have permanent year-round positions!
For project work, think: AAPC, CSI, Judge Group, Norwood, Advantmed, A-Line Staffing, Amergis, ECLAT - just to name a few!
💡 Psst… some companies might even keep you around for multiple sparkly projects if you shine bright enough! 🌈
📅 What’s the Work Like?
Project work is like enchanted quests: exciting but temporary.
⏳ Expect some downtime between missions.
🎯 Projects vary in length, focus, and expectations.
🌟 Some full-time gigs start as temporary.
🧩 You might be on multiple projects at once, so:
🗂️ Stay mega-organized
📋 Match payer rules to the right project
🧭 Know which guideline applies where
💡 Uni Tip! 🗃️🦄📂
Uni’s got bookmarks and folders galore! Use folders (digital or physical!) to keep specific project documents, guidelines, and notes organized. A tidy unicorn is a successful one!
✨ Think of it like juggling different enchanted scrolls; each one with its own rules, rewards, and timelines. Balance is key, magical multitasker! 🪄📚⏳
🎯 How to Sparkle on a Project
Companies usually expect:
💎 95%+ coding accuracy to stay on the team
⚡ Productivity goals (varied by company)
Do your best magic every chart!
✨Project coding is a wild adventure. Stay curious, stay prepared, and keep that sparkle strong!
🧠 Uni’s Coding Tips for Project Pros
Wanna stay legendary? Don’t forget to:
🧾 Include all relevant codes:
Combo codes (like HTN + CKD)
SDOH Z-codes
NEC and Other Specified codes
Both HCC and non-HCC codes, only in certain projects
📚 Follow AHA Coding Clinics and:
Stay current with ICD-10 October updates
Understand HCC model changes (V24 → V28)
⚠️ Each payer has their own spellbook (aka documentation rules). Know 'em!
🔗 See “Uni’s Secret Scrolls” above for links, tools, and coding guides
🌟 Advice for New Coders: From One Unicorn to Another
Welcome to the wild, wonderful world of coding! Whether you're just starting out or deep into your first few charts, here are a few magical reminders to keep in your coding toolkit:
💬 Feedback isn’t failure, it’s fuel. Every correction is a chance to grow, sharpen your skills, and code stronger next time.
🔄 Adaptability is your superpower. Guidelines change, policies change, and platforms change. You’ve got this if you stay flexible and curious.
🧠 Different minds read things differently. Keep an open heart and don’t be afraid to ask questions or see things from another angle.
☁️ Negativity exists, but don’t let it dim your sparkle. Protect your mindset. Stay positive, stay focused, and don’t hesitate to reach out to experienced coders. So many of us want to help.
🦄 You belong here. You’re not just learning codes, you’re learning how to speak the language of healthcare. And that’s powerful.
✨ Keep going, keep growing, and remember, even the most magical coders were once beginners.
📝 Uni’s Resume Wisdom
Let your resume shine like your glitter trail! Include:
🪪 Your AAPC or AHIMA credentials + member ID
💼 All relevant experience
🔍 Add Key terms from job listings so recruiters find you fast. Like, action verbs to lead bullet points: Abstracted, Analyzed, Validated, Audited, Interpreted, Coded, Reported, Collaborated, Educated, Improved...
💡 Some bullet point examples:
Proficient in Risk Adjustment coding, including HCC mapping, MEAT criteria validation, and RAF score capture
Skilled in ICD-10-CM coding with emphasis on chronic condition abstraction and accurate code selection
Experienced in retrospective, prospective, and concurrent chart reviews across diverse medical specialties
Knowledgeable in CMS-HCC models (V24 & V28) and documentation compliance standards
Strong in EHR navigation and code validation using platforms like Epic, Cerner, and encoder tools
📍 Heads up: Pay can vary by region, so do your homework!
Until next time,
✨ Code Smarter. Lead Stronger. Sparkle More.
- 🦄 Little Uni, Talia Fortier (CPC, CPMA, CRC, Approved Instructor), Dawn Newman (CPC, CRC), Debbie Jimenez (CPC, CPMA, CRC)