As the healthcare industry continues to shift towards value-based reimbursement, accurately capturing patient conditions through risk adjustment coding has never been more important to estimate future healthcare outcomes and cost. While there are many variables, including demographic characteristics and health status, to calculate the risk of a patient population, the primary factor to consider are the patient’s diagnosis codes. The resulting score reflects how much a provider should spend on taking care of their patients in a year. Without accurate data capture, the supporting diagnosis coding would be inaccurate, which can impact healthcare services, outcomes, and reimbursement.
As one of the leading risk adjustment coding companies, 3Gen Consulting offers comprehensive risk adjustment documentation and coding services by promoting precise clinical documentation and supporting it with accurate diagnosis coding. Our risk adjustment coding solutions are designed to provide a complete picture of a patient’s health to develop better care plans, improve outcomes, reduce costs, and receive optimal reimbursement.
The Hierarchical Condition Category (HCC) Coding Model is an advanced risk-adjustment model designed to better estimate future health care costs for patients. The HCC risk adjustment model assigns a risk score, also called the Risk Adjustment Factor (RAF), to each eligible beneficiary, which is based on the beneficiary’s health condition as well as demographic characteristics such as age,gender, institutional status, etc. This model groups clinically related diagnosis codes on resource use, meaning that the higher the risk score, the higher the anticipated cost.
It is important to note that while for billing purposes, the diagnosis codes selected are to identify the reason for a visit or treatment; for risk adjustment purposes, all diagnosis for all current conditions must be captured without regard to current treatment and must be supported by documentation. This is where we, as an HCC coding company, can help! Our HCC risk adjustment coders will ensure documentation is complete, assign appropriate diagnosis codes if the conditions meet the TAMPER (treatment, assessment, monitor/medicate, plan, evaluate, or referral) or MEAT (monitor, evaluate, assess, or treat) criteria and ensure health plans, Accountable Care Organizations (ACOs), and providers are compensated accurately and are providing the highest level of care.
To ensure that risk scores are accurately reflected at the member and population levels, it is critical to understand and have access to the various data elements for precise risk adjustment documentation & coding.
To calculate beneficiaries’ risk score, the risk adjustment model factors in several classification levels to map National Drug Codes (NDCs) up to HHS Drug Classes (RXCs). It is crucial to bill the precise number of NDC units for the corresponding HCPCS/CPT codes on your claims to enable more accurate payments and better drug cost management based on what was administered and billed.
Due to the nuances associated with risk adjustment documentation and coding, many organizations need to invest in a dedicated team of certified risk adjustment coders to ensure accuracy and compliance with the regulatory requirements, which can be expensive. An alternative would be partnering with a risk adjustment coding company with experience in providing HCC coding services.
If the patient information is incorrect or not documented properly it will lead to less reliable risk score calculations, risking inaccurate representation of their members health needs. Adapting to the ever-changing healthcare landscape and keeping up with HCC documentation requirements is extremely important to maintain data accuracy and remain in compliance.
HCC risk adjustment is based on physician-coded documents, claims coded by back-office personnel, and codes entered by HCC medical coders. A single mistake or misinformation can affect the rest of the chain at any point in the process.
Concurrent risk adjustment enables real-time RAF score optimization by capturing and coding conditions during ongoing care. 3Gen’s solution integrates with clinical workflows, allowing providers to address gaps immediately — reducing downstream audit risks and improving both compliance and patient outcomes.
How does prospective risk adjustment benefit payers and providers compared to retrospective reviews?
Prospective risk adjustment enables proactive HCC capture before the encounter ends — leading to better risk stratification, accurate resource allocation, and optimized revenue. 3Gen’s certified risk adjustment coders and clinical review processes ensure high capture rates, reducing RAF leakage before final submission.
Yes. 3Gen’s risk adjustment management framework supports hybrid models — combining concurrent, prospective, and retrospective review processes. Our coders are trained to pivot strategies based on project goals, risk score trends, and submission deadlines.
RAF leakage often results from incomplete documentation, missed HCCs, and invalidated codes. 3Gen mitigates this through a combination of NLP-enabled document review, intelligent coder workflow queues, and real-time feedback loops to providers — improving coding completeness and submission integrity.
