RxHCC Model
November 3, 2020The second major HCC based risk adjustment model is the RxHCC model. The RxHCC model was created for Medicare Part D and Medicare Advantage plans. This model, like the CMS HCC model, can predict benefit costs that the plan will be responsible for covering and adjust standardized payments based on the underlying health status of the plan’s members.
Rx condition categories describe major diseases and are broadly organized into body systems. Like the HCC model, they’re also categorized into hierarchies. This prevents multiple diagnoses in the same disease group from increasing the risk score when they shouldn’t.
An RxHCC risk score of 1.0 means a member covered by standard Part D Medicare benefits is expected to incur the average liability amount for prescription drugs.
These are some examples of RxHCC diagnoses that are commonly overlooked in yearly reports:
| RxHCC | Diagnoses | ICD-10 Code |
|---|---|---|
| 134 | Major depressive disorder, single episode, unspecified | F32.9 |
| 188 | Old myocardial infarction | I25.2 |
| 187 | Essential (primary) hypertension | I10 |
| 166 | Most Migraine diagnoses | G43.001-G43.919 |
| 87 | Age related osteoporosis without current pathological fracture | M81.0 |
| 68 | Gastroesophageal reflux disease without esophagitis | K21.9 |
| 45 | Pure hypercholesterolemia | E78.00 |
| 42 | Hypothyroidism, unspecified | E03.9 |
| 226 | Mild persistent asthma, uncomplicated | J45.30 |
| 226 | Mild intermittent asthma, uncomplicated | J45.20 |
| 315 | Psoriasis vulgaris | L40.0 |
CMS website Medicare Managed Care Manual Chapter 7 Risk Adjustment