HL7 Terminology (THO)
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HL7 Terminology (THO), published by HL7 International - Vocabulary Work Group. This is not an authorized publication; it is the continuous build for version 5.0.0). This version is based on the current content of https://github.com/HL7/UTG/ and changes regularly. See the Directory of published versions

CodeSystem: CMS Prescription Drug Hierarchical Condition Categories

Official URL: http://terminology.hl7.org/CodeSystem/cmsrxhcc Version: 1.0.1
Active as of 2021-12-02 Responsible: Centers for Medicare & Medicaid Services Computable Name: CMSRxHCC

Starting in 2006, with the implementation of the Part D program, CMS introduced a second major HCC-based risk adjustment model. Created with the passage of the Medicare Modernization Act (MMA) of 2003, the Medicare Part D Prescription Drug benefit became the second major Medicare capitated payment system. CMS developed the Part D RxHCC risk adjustment model to apply to monthly capitated payments to both Medicare Advantage (MA-PDs) and standalone prescription drug plans (PDPs). The Part D RxHCC risk adjustment model implemented in 2006 was developed using a structure similar to the CMS-HCC model, in that it included demographic and diagnosis information clustered into hierarchical condition categories. CMS obtains diagnoses for all Medicare beneficiaries from either fee-for-service claims or Medicare Advantage reporting. In 2011, CMS implemented an updated Part D RxHCC risk adjustment model, incorporating program data derived from prescription drug event (PDE) data. The data used to calibrate this updated model was more recent cost and utilization data, resulting in a model that reflects more recent drug cost and utilization patterns.

For more information, see: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors

The CMS RxHCCs are in the public domain and are free to use without restriction.

This Code system is referenced in the content logical definition of the following value sets:

This CodeSystem is not used here; it may be used elsewhere (e.g. specifications and/or implementations that use this content)

This code system http://terminology.hl7.org/CodeSystem/cmsrxhcc defines many codes, but they are not represented here


History

DateActionCustodianAuthorComment
2022-07-22reviseTSMGJessica BotaAdd default value of TRUE for code systems missing caseSensitive element unless otherwise specified; UP-322
2022-01-29createHTAJessica BotaAdd CMS Prescription Drug Hierarchical Condition Categories per HTA; up-269