Risk Adjustment & HCC Coding Services
MedCodex provides comprehensive risk adjustment coding to support Medicare Advantage plans, ACOs, and value-based care programs. Our HCC specialists ensure complete and accurate Hierarchical Condition Category (HCC) capture, RAF score optimization, and compliance with CMS risk adjustment data validation (RADV) requirements.
What We Do
- Prospective and retrospective HCC coding reviews
- RAF score calculation and gap analysis
- Chronic condition identification and closure
- RADV audit support and documentation improvement
- Annual wellness visit (AWV) coding support
- Care gap identification and reporting
HCC Model Expertise
We support both CMS-HCC (v24, v28) and HHS-HCC models used by Medicare Advantage plans and ACA marketplace payers. Our coders understand the hierarchical relationships between HCC categories and ensure that the most clinically specific codes are captured to reflect true patient complexity.
Prospective vs. Retrospective Reviews
Prospective Reviews: Conducted before or during the care year. Our coders review scheduled patient encounters and flag chronic conditions that should be addressed and documented at the visit, closing care gaps in real time.
Retrospective Reviews: Conducted after the service year. We review medical records to identify HCC conditions that were diagnosed and treated but not coded on submitted claims, supporting supplemental data submissions.
Compliance & RADV Readiness
CMS RADV audits can result in significant recoupment if HCC coding is not supported by medical record documentation. MedCodex ensures that every HCC code is fully documented and defensible, reducing your RADV risk and preparing your organization for audit.
Why HCC Accuracy Matters
Every uncaptured HCC represents lost revenue for health plans and risk-bearing providers. Studies show that the average Medicare Advantage member has 2–3 HCC conditions that go uncoded each year. Our thorough review process closes those gaps, improving RAF scores and ensuring your capitation payments accurately reflect your patient population's true health status.
Why Choose MedCodex for Risk Adjustment & HCC Coding?
Frequently Asked Questions
How does MedCodex ensure all relevant HCCs are captured accurately for each patient encounter?
Our AAPC/AHIMA-certified coders (CPC/CCS) are trained specifically in CMS-HCC risk adjustment models and review the full clinical documentation, including problem lists, diagnoses, and physician notes, to identify every reportable chronic condition. A multi-level QA process audits coded charts before submission to achieve 98%+ accuracy. This directly reduces the risk of under-coded RAF scores that leave reimbursement on the table.
What does the free pilot involve for a Medicare Advantage plan or value-based care practice?
We code a sample set of your actual charts at no cost and with no commitment required, so you can evaluate HCC capture rates, RAF score impact, and turnaround time against your current performance. The pilot includes a summary report comparing our findings to the original coding, highlighting any missed or under-documented HCCs. No contract is signed and no fee is charged until you choose to move forward.
How do you handle PHI and HIPAA compliance when coding our risk adjustment charts?
MedCodex operates under fully HIPAA-compliant processes, and a signed Business Associate Agreement is executed before any patient data is accessed or shared. Our coders access your charts through secure remote access directly inside your existing EHR or billing platform, so PHI never leaves your system environment. We do not store or transfer identifiable patient data to external servers.
How is risk adjustment coding work priced, and does it scale with our patient volume?
Pricing is offered on a flexible per-chart basis for practices with variable encounter volumes, or as a dedicated FTE model for organizations that need consistent daily throughput across large populations. This means you pay for actual work completed rather than a fixed overhead, and the model can shift as your Medicare Advantage or value-based care panel grows or contracts. Your dedicated account manager will recommend the right structure based on your volume profile.
What is the standard turnaround time, and how does MedCodex integrate with our existing coding or CDI team?
Standard turnaround for risk adjustment charts is 24 to 48 hours from receipt, supporting both prospective and retrospective coding workflows. Our coders work directly inside your EHR or billing platform via secure remote access, so there is no disruption to your existing system setup or internal team processes. A dedicated account manager serves as the single point of contact to coordinate handoffs, answer queries, and align our workflow with your internal CDI or compliance staff.