After codes are submitted to Medicare, what is calculated for each patient?

After codes are submitted to Medicare, what is calculated for each patient?

• A. Adjustment factor
• B. Risk score for each patient
• C. Length of stay
• D. Payment amount

Answer: (B)

After codes are submitted, Medicare computes a patient-specific risk score through risk adjustment. This score comes from mapping the diagnosis codes to hierarchical condition categories (HCCs), each with a weight, and then combining those weights with demographic factors like age and sex. The resulting numeric risk score estimates the expected costs for that patient and is used to adjust payments in risk-based programs—the sicker the patient, the higher the score and the higher the adjusted payment. Length of stay is an outcome, not a code-derived metric, and while payments are influenced by the risk score, the key calculation made from the submitted codes is this per-patient risk score.

After codes are submitted, Medicare computes a patient-specific risk score through risk adjustment. This score comes from mapping the diagnosis codes to hierarchical condition categories (HCCs), each with a weight, and then combining those weights with demographic factors like age and sex. The resulting numeric risk score estimates the expected costs for that patient and is used to adjust payments in risk-based programs—the sicker the patient, the higher the score and the higher the adjusted payment. Length of stay is an outcome, not a code-derived metric, and while payments are influenced by the risk score, the key calculation made from the submitted codes is this per-patient risk score.