2027 Risk Adjustment Coding and HCC Guide

• New — Updated format for Chapters for Coding and Documentation.   Reorganization of coding and documentation chapters making it easier to find the coding and documentation guidelines, examples and tips to validate HCC selections. 
• Optum Edge — Understand risk adjustment coding and HCCs. Explanations provided on the three types of HCCs covered under Medicare, CMS-HCC, Rx-HCC, and ESRD/PACE-HCC. HSS-HCCs used for commercial plans and VBR programs are also explored.
• Optum Edge — Easy-to-use tables of HCCs. RxHCC and CMS-HCC Model risk adjustment tables are included.
• Optum Edge — Calculate RAF scores. Use the HCC tables to identify conditions impacting health status and cost of care. Calculate RAF scores for your patients to quantify risk. 
• Optum Edge — Learn which demographic factors and conditions impact risk. Discover the role chronic conditions play in overall risk adjustment, how the risk adjustment factor (RAF) score is calculated, and how the cumulative RAF score for covered beneficiaries drives payments to health plans. 
• Understand the provider’s role. Documentation and coding are the basis for delineating health status and calculating risk. Use the clinical documentation improvement tips to increase coding specificity, translating into accurate RAF scores.
• Access to data files online.  The CMS-HCC and HSS-HCC data files are provided on the Optum Product Update page on optumcoding.com.  

Anita Schmidt has expertise in ICD-10-CM/PCS, DRG, and CPT with more than 20 years’ experience in coding in multiple settings, including inpatient, observation, and same-day surgery. Her experience includes analysis of medical record documentation, assignment of ICD-10-CM and PCS codes, and DRG validation. She has collaborated with clinical documentation specialists to identify documentation needs and potential areas for physician education. Most recently she has been developing content for resource and educational products related to ICD-10-CM, ICD-10-PCS, DRG, and CPT. Anita is an AHIMA-approved ICD-10-CM/PCS trainer and is an active member of the American Health Information Management Association (AHIMA) and the Minnesota Health Information Management Association (MHIMA).

Laura Anderson is a Registered Nurse and CDI Specialist/Educator with more than 20 years of experience in the health care profession. She obtained her BSN at the University of Minnesota and spent most of her bedside nursing career on Medical-Surgical care units. Her clinical documentation experience began in 2007, covering CDI specialist training, education development, and physician engagement. She has served as a CDI Team Lead and consultant, working with senior leadership to incorporate CDI work into documentation compliance and quality metrics. Laura also has a BS degree in Biology (Winthrop University), with research experience in liver cancer and radiation-induced leukemia. She has presented at the state and national levels for the Association of Clinical Documentation Integrity Specialists (ACDIS) and has served as a co-lead for the Minnesota state chapter.