HL7 Terminology (THO)
6.0.0 - Publication International flag

This page is part of the HL7 Terminology (v6.0.0: Release) based on FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version. For a full list of available versions, 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)

Generated Narrative: CodeSystem cmsrxhcc

This case-sensitive code system http://terminology.hl7.org/CodeSystem/cmsrxhcc defines codes, but no codes are represented here


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