Empowering healthcare organizations with smarter risk analytics

How a diagnosis turns into a number. Read it top to bottom like a flowchart.

STEP 1 ▸ Diagnosis A condition is documented and coded at a real encounter. No diagnosis, no signal: it has to be on the record.

STEP 2 ▸ Maps to an HCC Eligible diagnoses roll up into a Hierarchical Condition Category, a group of clinically related conditions.

STEP 3 ▸ Carries a weight Each HCC has a coefficient. More resource-intensive categories tend to carry more weight.

STEP 4 ▸ Add the demographics Combine the condition weights with member factors: age, sex, dual-eligible status.

STEP 5 ▸ RAF score The total is the Risk Adjustment Factor. Average member ≈ 1.0.

One honest note: hierarchies mean only the most severe condition in a family usually counts. You don't stack every related code. Accuracy, not volume.

See the full HCC and RAF pipeline laid out with examples.

See also: what a RAF score is, explained from scratch.

Pipeline is illustrative; any weights/values shown are illustrative, not real CMS values.

Not coding/billing/clinical advice. Confirm against the current CMS Rate Announcement. — Chin Ramamoorthi, CEO, VBC Risk Analytics. Reviewed by the VBC RA Risk Adjustment & Coding Team.

How a diagnosis turns into a number. Read it top to bottom like a flowchart.

STEP 1 ▸ Diagnosis A condition is documented and coded at a real encounter. No diagnosis, no signal: it has to be on the record.

↓

STEP 2 ▸ Maps to an HCC Eligible diagnoses roll up into a Hierarchical Condition Category, a group of clinically related conditions.

↓

STEP 3 ▸ Carries a weight Each HCC has a coefficient. More resource-intensive categories tend to carry more weight.

↓

STEP 4 ▸ Add the demographics Combine the condition weights with member factors: age, sex, dual-eligible status.

↓

STEP 5 ▸ RAF score The total is the Risk Adjustment Factor. Average member ≈ 1.0.

One honest note: hierarchies mean only the most severe condition in a family usually counts. You don't stack every related code. Accuracy, not volume.

See the full HCC and RAF pipeline laid out with examples.

See also: what a RAF score is, explained from scratch.

Pipeline is illustrative; any weights/values shown are illustrative, not real CMS values.

Not coding/billing/clinical advice. Confirm against the current CMS Rate Announcement. — Chin Ramamoorthi, CEO, VBC Risk Analytics. Reviewed by the VBC RA Risk Adjustment & Coding Team.