Currentblue cross blue shield - tennesseePolicy N/A

Part D - Prescription Hierarchical Condition Categories (RxHCC)

Defines the Part D (RxHCC) risk-adjustment concept and lists diagnosis codes/descriptions used to capture prescription-related risk scores for Medicare Advantage members; intended for providers and coders documenting diagnoses for Part D risk adjustment.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyPart D - Prescription Hierarchical Condition Categories (RxHCC)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument diagnoses from an in-person visit and include corresponding ICD-10 codes on the claim to ensure Part D (RxHCC) risk adjustment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1,432diagnoses only risk-adjustable with the RxHCC model

Part Dcomponent of CMS risk adjustment focused on prescription drug costs

multipleexample diagnosis codes provided in document

Diagnosis Codes (Examples)

Anxiety, Other Psychiatric Disorders; Asthma/COPD groupICD-10

F411	Generalized anxiety disorder
F410	Panic disorder [episodic paroxysmal anxiety]
F4321	Adjustment disorder with depressed mood
F4310	Post-traumatic stress disorder, unspecified
F4323	Adjustment disorder with mixed anxiety and depressed mood
J45909	Unspecified asthma, uncomplicated
J4520	Mild intermittent asthma, uncomplicated
J4540	Moderate persistent asthma, uncomplicated
J4530	Mild persistent asthma, uncomplicated

Policy Summary

Payerblue cross blue shield - tennessee

PolicyPart D - Prescription Hierarchical Condition Categories (RxHCC)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument diagnoses from an in-person visit and include corresponding ICD-10 codes on the claim to ensure Part D (RxHCC) risk adjustment.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

What Providers Must Do

Note

Prior authorization — Not applicable

Not applicable — this document explains risk adjustment and diagnosis capture; it does not establish prior authorization rules.

Note

Provider-facing highlight

To help capture RxHCC diagnoses, many conditions have been added to the electronic patient assessment form. Remember that diagnoses entered only on a prescription or submitted to a pharmacy do NOT count toward Part D (RxHCC) risk adjustment.

Documentation Required

Documentation requirements for RxHCC

Diagnosis must be supported by medical record documentation from an in-person visit and the corresponding ICD-10 diagnosis code must be included on the claim. The RxHCC model does not accept diagnoses that are only recorded on prescriptions sent to pharmacies. Accurate, in-person visit documentation and correct coding on the claim are required to capture Part D (RxHCC) diagnoses.

Diagnosis documented during an in-person visit
Corresponding ICD-10 code present on the claim
Do NOT rely on pharmacy prescription diagnosis fields for RxHCC capture
Use the electronic patient assessment form to document RxHCC-eligible conditions

Policy Background

RxHCC is the Part D component of the CMS Hierarchical Condition Category (HCC) risk adjustment model used to predict expected prescription drug costs for Medicare beneficiaries by mapping ICD-10 diagnosis codes to hierarchical condition categories. Risk adjustment assigns each member a risk score based on demographics and documented diagnoses; the RxHCC model specifically determines the diagnosis component of the Part D (prescription drug) risk score. (See CMS HCC framework and Part D/RxHCC description.)

Accurate documentation from an in-person visit and inclusion of the corresponding ICD-10 diagnosis code on the claim are required for diagnoses to count toward Part D risk adjustment. Adding a diagnosis only to a prescription transmitted to the pharmacy does not meet the documentation requirement and will not be included in RxHCC calculations. The Inflation Reduction Act of 2022 expanded the portion of drug spending subject to Part D risk adjustment, increasing the importance of correct diagnosis capture for chronic conditions; note that 1,432 diagnoses map only to the RxHCC model and are therefore captured solely through Part D documentation pathways.

Key Terms

inv-09: RxHCC — The Part D component of CMS hierarchical condition category risk adjustment used to predict prescription drug costs.

DefinitionRxHCC: The Part D component of the CMS Hierarchical Condition Categories (HCC) risk‑adjustment model used to predict expected prescription drug costs for Medicare beneficiaries.

PurposeUsed by CMS to determine the diagnosis component of an individual’s Part D risk score by mapping ICD‑10 diagnosis codes to RxHCCs.

ScopeFocuses specifically on prescription drug cost prediction within the broader CMS‑HCC framework that assigns risk scores based on demographics and diagnoses.

inv-10: HCC — Hierarchical Condition Category — grouping of diagnosis codes used by CMS to adjust risk scores for expected healthcare costs.

DefinitionHCC: Hierarchical Condition Category — a grouping of ICD‑10 diagnosis codes used by CMS to adjust risk scores for expected healthcare costs.

FunctionMaps significant diagnosis codes to condition categories that contribute to the diagnosis component of an individual’s overall CMS risk score.

Relationship to RxHCCThe RxHCC model is the Part D portion of the CMS‑HCC framework, applying the HCC concept specifically to predict prescription drug costs.

I2510	Atherosclerotic heart disease of native coronary artery without angina pectoris
I252	Old myocardial infarction
I255	Ischemic cardiomyopathy
I25810	Atherosclerosis of coronary artery bypass graft(s) without angina pectoris
I259	Chronic ischemic heart disease, unspecified
I2584	Coronary atherosclerosis due to calcified coronary lesion
F32A	Depression (unspecified code string as presented)
F329	Depression, unspecified
F341	Dysthymic disorder
E785	Hyperlipidemia, unspecified

E039	Hypothyroidism, unspecified
E038	Other specified hypothyroidism
E041	Nontoxic single thyroid nodule
E890	Postprocedural hypothyroidism
E042	Nontoxic multinodular goiter
E079	Disorder of thyroid, unspecified
E063	Autoimmune thyroiditis
E0590	Thyrotoxicosis, unspecified without thyrotoxic crisis or storm