The Importance of Specificity in Coding

Hierarchical condition categories (HCCs) utilize ICD-10 codes to determine risk scores for patients. Each applicable HCC is added up to determine the patient’s total risk adjustment factor (RAF). It is imperative to code with as much specificity as possible, in order to fully encapsulate the amount of resources expected to be needed for the patient. This is the goal of HCCs and RAF scores.


Below is an example of the material financial impact of coding with as much specificity as possible. With the least amount of specificity, the provider would receive $452 per member, per month ($5,418 annually). With the maximum specificity, the provider would receive $1,381 per member, per month ($16,573 annually). The difference between the two examples, on an annual basis, is $11,155 for one member. This example clearly illustrates the importance of increased specificity in coding.




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