NATIONAL BUREAU OF ECONOMIC RESEARCH
NATIONAL BUREAU OF ECONOMIC RESEARCH

CMS Risk Adjustment

CMS implemented the Hierarchical Condition Categories (HCC) model in 2004 to adjust capitation payments to Medicare Advantage plans for the health expenditure risk of their enrollees.

CMS' Risk Adjustment materials include a lot of information such as an

The 2012 Version 12 model expects two datafiles: PERSON and DIAG.

The variables needed in the PERSON dataset from the enrollment file are the following:

Variable NameVariable TypeDescription
HICNOCharacter or NumericBeneficiary identifier
SEXCharacterSex of a a beneficiary, "1"=male; "2"=female.
DOBDateDate of birth of a a beneficiary in SAS date format (January 1, 1960 = 0)
MCAIDNumeric1 = Number of State Part B BUYIN (Medicaid) Months of base year > 0; 0 = Otherwise
NEMCAIDNumeric1 = if a new enrollee and number of State Part B BUYIN (Medicaid) Months of base year > 0; 0 = Otherwise
ORECCharacterOriginal reason for entitlement, "0" - old age (OASI); "1" - disability (DIB); "2" - End Stage Renal Disease (ESRD); "3" - both DIB and ESRD

The variables needed in the DIAG dataset from the MedPAR, outpatient, and carrier data are the HICNO and DIAG, the ICD-9-CM diagnosis code from (1) principal hospital inpatient (2) secondary hospital inpatient (3) hospital outpatient (4) physician, and (5) clinically-trained non-physicians (e.g. psychologist, podiatrist).

CMS delivers the SAS code model files with ".TXT" extensions. By convention, SAS code usually has a ".sas" extension. The 2012 Version 12 main program V1212F1P.sas calls the main macro program V1212F1M.sas which in turn calls AGESEXNV.sas EDITICD9.sas V12H70L1.sas V12H70H.sas V12H70M.sas and SCOREVAR.sas

SAS can create new variables using formats. The models use the diagnosis codes to create Condition Categories (CCs). Then the program creates hierarchical condition codes by imposing hierarchies on the CCs. CMS delivers the formats as SAS transport files and (usually) also as a text file for reference. The SAS transport files can (and have been!) converted to regular SAS data files using SAS' PROC CIMPORT.

A worked example using the HCC 2014 Version 12 final model on made up input data and the data the model outputs is available. The 2014 HCC 12 model uses ICD9 codes.

Made up input data files for the HCC 2016 Version 22 model are available too. The HCC 2016 22 model can use ICD9 or ICD10 codes.

Jean Roth set up the Risk Adjustment materials here to make it a bit easier to get familiar with the CMS Risk Adjustment software model materials.

CMS Risk Adjustment Model Materials

Year
Type
Version
Source Materials
Documentation
HCCCOEFN
Model Coefficients
Formats
Description
Word
PDF
SAS Transport
Stata
SAS
CSV
Desc
SAS Transport
SAS7BCAT
TXT
2017 HCC 21
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
ICD10
desc
2017 HCC 22
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
ICD10
desc
2017 HCC ESRD 21
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
ICD10
desc
2017 RxHCC 5
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
ICD10
desc
2016 HCC 21
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
ICD10
ICD9
desc
2016 HCC 22
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
ICD10
ICD9
desc
2016 HCC ESRD 21
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
ICD10
ICD9
desc
2016 RxHCC 5
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
ICD10
ICD9
desc
2015 HCC 12
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2015 HCC 21
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2015 HCC 22
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2015 HCC ESRD 21
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2015 RxHCC 3
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2014 HCC 12
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2014 HCC 21
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2014 HCC 22
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2014 HCC ESRD 21
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2014 RxHCC 3
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2013 HCC 12
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2013 HCC 21
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2013 HCC ESRD 21
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2013 RxHCC 3
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2012 HCC 12
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2012 HCC ESRD 21
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2012 RxHCC 3
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2012 HCC PACE 21
source
doc
pdf
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2011 HCC 12
source
doc
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2011 HCC ESRD 12
source
doc
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2011 RxHCC 3
source
doc
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2010 HCC 12
source
doc
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2010 RxHCC 1
source
doc
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2009 HCC 12
source
doc
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2009 HCC ESRD 12
source
doc
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2009 RxHCC 1
source
doc
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2008 HCC ESRD 12
source
doc
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2007 HCC 12
source
doc
exp
dta
sas7bdat
csv
desc
exp
bcat
txt
desc
2007 RxHCC 1
source
doc
exp
dta
sas7bdat
csv
desc
exp
bcat
N/A
desc
2006 RxHCC 1
source
doc
exp
dta
sas7bdat
csv
desc
exp
bcat
N/A
desc

The risk adjustment software and files often have names like the following:

AGESEX*TXT macros to create demographic variables used in regressions.
EDITICD9.TXTmacros to make age/sex edits on ICD9 codes
F*TXT cross-walk from ICD9 codes to CC categories
SCOREVAR.TXTmacro to calculate SCORE variable
V12H70H.TXT HCC HIERARCHIES: version 12 of HCCs only 70 CMS HCCs are included
V12H70L1.TXT HCC version 12 labels for 70 HCCs
V12H70M.TXT to assign additional CC for some ICD9s
Vnnnn?1M.TXT Main SAS macro. Creates HCC and score variables for each person who is present in a person file.
R02X78H1.TXTRXHCC hierarchies for RXHCCs that are included in software
R02X78L1.TXTRXHCC labels
R02X78M2.TXTto assign multiple RXs for some ICD9s codes
R*P.TXT Job Control Language (JCL) for IBM mainframe
R*EDIT*.TXT age/sex edits on ICD9 codes
E?????1M.TXTcreates HCC and score variables for each person who is present in a person file.
E*P.TXT Job Control Language (JCL) for IBM mainframe
E12H70H.TXT HCC HIERARCHIES: version 12 of HCCs only 70 CMS HCCs are included

The files beginning with "R" usually are RxHCC model files.
The files beginning with "E" usually are ESRD model files.
JCL is Job Control Language.


To report errors, or if you have comments or suggestions, e-mail jroth@nber.org.

Last Update: May 8, 2017 Created by Jean Roth August 2, 2014

 
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