Q&A: CMS HCCs versus HHS HCCs

Q: Are the diagnoses on the CMS HCC list the exact same as the ones on the Department of Health and Human Services (HHS) HCC list?

A: The HHS HCCs are the ones used for calculating payment for government insurance programs offered through what we think of as the marketplace as part of the Affordable Care Act. The program has a lot of similarities to Medicare Advantage, which uses the CMS HCCs--they are both  risk-adjusted and both use demographics and diagnostic information to calculate scores. The two programs also have the same overarching goal—o ffering incentives for payers to cover sicker individuals as well as healthy individuals in a budget-neutral manner, which is the intention of all risk-adjustment.

However, the HHS program is slightly different because it is for those of non-Medicare age, which would include patients from infants to adults. Therefore, the inclusive diagnosis list is going to be much more extensive, because they’re going to have to include things like pregnancy and congenital conditions that could range from cleft lips to Down’s syndrome. There’s some similarities in diagnoses, like cancer and sepsis and drug dependence .

Unlike the CMS HCCs which predict future expenditures based on past diagnoses, the HHS HCCs are considered a concurrent model, where the diagnostic information that they gather is used from the current year to calculate current year expenditures.

Editor’s note: Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, director of HIM and coding for HCPro in Middleton, Massachusetts, answered this question during our 2016 CDI Week Webcast, Risk Adjustment Documentation and Coding. For more information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com.