Which of the following is a requirement for diagnosis coding in CMS HCC?

The requirement for diagnosis coding in the CMS Hierarchical Condition Categories (HCC) model emphasizes that the diagnosis must originate from specific provider types. This is crucial for ensuring the accuracy and reliability of the risk adjustment process. Providers such as physicians, nurse practitioners, and physician assistants are considered credible sources for diagnosis documentation. These specific provider types are necessary because they typically have the required training and responsibility to accurately capture the patient’s health status, which is essential for effective risk adjustment and reimbursement.

This approach also helps to standardize the quality of data collected, as these providers follow clinical guidelines and coding protocols, ensuring that the diagnoses reported are supported by clinical evidence. By using diagnoses from designated provider types, CMS aims to enhance the integrity of the data used in the HCC model, ultimately impacting the determination of reimbursement rates for Medicare Advantage plans.