Supporting risk capture

HCC risk recapture

In value-based care models, accurately capturing Hierarchical Condition Categories (HCC) improves both patient risk stratification and reimbursement. HCC codes represent chronic conditions and other risk factors that predict a patient’s future healthcare utilization and costs. However, some patients may have conditions that were documented in previous years but have not been actively captured in more recent assessments. This results in missed opportunities for risk adjustment and appropriate care management.

The goal of HCC risk recapture analysis is to identify patients whose chronic conditions, indicated by specific HCC codes, were recorded by external provider organizations within the past 2 years, but were not recorded by a Zus customer. Recapturing these codes through proper documentation and coding ensures accurate risk adjustment, improves patient care by aligning treatments with known conditions, and secures appropriate reimbursement.

To assist with such analyses, Zus enriches Condition resources with context-appropriate categories, in this case grouping ICD-10 codes into Hierarchical Condition Categories.

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Sample query available here