CRC (Court Reporting Certifications) key terms

A grouping of ICD-10-CM diagnosis codes that maps to a single risk weight used in risk adjustment models; each enrollee's HCCs combine to produce a risk score.

A numeric value summarizing expected healthcare costs for an individual relative to the average beneficiary, calculated from demographic factors and documented HCCs in a given payment year.

A risk adjustment model used for Medicare Part D prescription drug coverage, grouping diagnoses and age/sex factors to predict drug costs separately from the medical HCC model.

The final risk score produced by a risk adjustment model after applying hierarchies, interactions, and demographic factors to the diagnoses submitted for an enrollee.

The calendar year in which a risk adjustment payment applies; diagnoses from a prior data collection year are used to calculate the score for this year.

The year in which diagnoses are captured from claims or encounters to calculate risk scores for a subsequent payment year, often with a specified submission deadline.

A rule within an HCC model that groups related conditions so that only the most severe or resource-intensive condition in a category contributes to the risk score.

A medical condition that coexists with the primary condition being treated; in risk adjustment, documented comorbidities can increase the RAF score when they map to distinct HCCs.

The clinical modification of the International Classification of Diseases, Tenth Revision, used in the United States to code diagnoses and support risk adjustment, quality reporting, and billing.

The level of detail in a diagnosis code that fully describes the condition's type, site, severity, and cause; higher specificity improves risk adjustment accuracy and compliance.

The designation of right, left, or bilateral for paired organs or body sites; many ICD-10-CM codes require laterality to be complete and accurately reflect the condition.

An ICD-10-CM instruction indicating that two codes cannot be reported together because the conditions are mutually exclusive; one must be selected based on documentation.

An ICD-10-CM instruction indicating that a condition is not included in the code's definition but may be reported separately when both conditions are present and documented.

Missing or insufficient clinical information in the medical record that prevents accurate code assignment, often requiring a provider query to clarify specificity, linkage, or clinical significance.

A formal communication to a provider requesting clarification or additional documentation to support accurate diagnosis coding, without leading the provider to a specific answer.

The clinical notes, test results, and other entries in a patient's chart that must support every diagnosis code reported for risk adjustment and billing purposes.

The order in which diagnosis codes are reported, typically placing the principal or first-listed diagnosis first, followed by secondary diagnoses that are relevant to the encounter.

The condition established after study to be chiefly responsible for the patient's admission or encounter, and the first diagnosis reported in the sequence.

The documentation that connects a manifestation or complication to an underlying disease, such as diabetic retinopathy linked to diabetes, required for correct combined code assignment.

A coding category requiring documentation that a specific complication (e.g., neuropathy, nephropathy, retinopathy) is due to diabetes, often needing a combination code and linkage statement.

A long-term condition of reduced kidney function staged by glomerular filtration rate; risk adjustment coding requires documenting the stage and any linkage to diabetes or hypertension.

Chronic obstructive pulmonary disease, a progressive lung condition often coded with specificity for exacerbation, obstruction type, and associated conditions such as asthma or tobacco use.

The assignment of ICD-10-CM codes for malignant neoplasms, requiring documentation of the primary site, histology, behavior, and any metastasis or treatment focus.

The spread of cancer from a primary site to a secondary site; coding requires distinguishing primary from secondary sites and documenting whether the encounter is for treatment of the primary or metastatic disease.

The coding of heart and blood vessel conditions such as heart failure, myocardial infarction, and hypertension, often requiring specificity for type, acuity, and causal relationships.

A legacy CMS system used by Medicare Advantage organizations to submit diagnosis data for risk score calculation, later supplemented by encounter data.

Claims-like records submitted by providers or health plans that capture diagnoses and services; CMS uses encounter data to calculate risk scores for Medicare Advantage enrollees.

A retrospective audit of medical records to verify that reported diagnosis codes are supported by documentation, often used to identify missed HCCs or coding errors.

A systematic examination of coding and documentation practices against CMS and other regulatory standards to ensure accuracy, detect fraud, and identify improvement areas.

The process of identifying and submitting all documented, clinically valid diagnoses that map to HCCs so that the calculated risk score reflects the enrollee's expected cost.

The submission of clinical performance measures (e.g., HEDIS, Star Ratings) that may be affected by diagnosis coding accuracy and documentation completeness.

Payment and care delivery models that reward providers for quality and cost efficiency, often relying on accurate risk adjustment to compare performance across patient populations.

A Medicare program option in which private plans provide benefits; these plans are paid using risk-adjusted capitation based on enrollee HCCs and demographic factors.

A permanent program under the Affordable Care Act that transfers funds among individual and small group market insurers to offset the cost of high-risk enrollees, using a separate HCC model.

An HCC identified during chart review as potentially present but not documented or coded, requiring validation before inclusion in risk score calculations.

The annual process of documenting and reporting chronic conditions that persist year after year so that they continue to contribute to the enrollee's risk score in the current payment year.

A documentation standard requiring that a condition be Monitored, Evaluated, Assessed, or Treated in the record to support code assignment for risk adjustment.