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EPM Tools - General Concepts about HCC/RxHCC
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In 2007, Medicare Advantage programs (HMO) were funded by CMS (Center for Medicare and Medicaid Services) using both demographics and the Hierarchical Conditional Codes known as the HCC Diagnoses.  2007 also became the year that RX HCC codes were added to complement the reimbursement for managing patients with other illnesses which while they did not rise to the level of complexity and cost-for-care, as the HCC diagnoses, they did qualify for a lower additional payment due to increased medication costs.

The RxHCC designations cover many diagnoses which were not covered in the HCC.  As a general rule almost all HCC diagnoses are also RxHCC codes but all RxHCC are NOT also HCC.  Here are some examples of diagnoses which are not HCC but are RxHCC codes:

  • Hypertension is not an HCC (i.e., 401.1 or  401.9, etc) but it is an RxHCC
  • Osteoporosis another common illness is not a medical HCC but is an RxHCC
  • CAD in itself is not a medical HCC, but it is an RXHCC.  Because CAD is a general term, it is imperative that if the patient has angina or an old MI, the chronic problem list should include angina or old MI as they are HCC diagnoses.

This tutorial details, SETMA’s solution to this complex but very important issue.

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