Do the HCC category hierarchies play a role in which medical record to submit for a RADV?

The hierarchies of Hierarchical Condition Categories (HCC) are essential for determining the appropriate medical records to submit during a RADV audit. HCCs are used to risk-adjust payments based on health status, with certain conditions having a higher impact on risk scores due to their complexity and resource needs.

When conducting a RADV audit, it is crucial to understand that certain HCCs can be more dominant based on their hierarchical structure. This means that if a patient qualifies for multiple HCCs, the highest-ranked category in the hierarchy will take precedence and influence the risk adjustment. Therefore, when selecting medical records for submission, it is important to consider both HCC category III and HCC category IV.

HCCs in category III may represent conditions that are expected to be treated and managed over time, while category IV may include more acute conditions that require different levels of care. The interplay between these categories impacts which medical records will most likely validate the risk-adjusted payments. Thus, choosing records that reflect both III and IV ensures adherence to the hierarchy and maximizes appropriate risk adjustment representation in the submitted data.

By incorporating records from both categories, auditors can demonstrate the full scope of a patient's health status and comply with the guidelines that govern