FIMC-HCC – Fellowship in Medical Coding-HCC by PMBAUSA LLC The FIMC-HCC (Fellowship in Medical Coding – HCC) by PMBAUSA LLC is an advanced professional training program designed to develop expertise in HCC Coding, Risk Adjustment Coding, and CMS Hierarchical Condition Category (HCC) Models under Medicare Advantage.

With the growing importance of Risk Adjustment Factor (RAF) scoring, V28 Model updates, and RADV audit compliance, accurate HCC coding has become critical for healthcare organizations, payers, and value-based care systems. The FIMC-HCC Fellowship equips medical coders, auditors, and consultants with structured knowledge and real-world case-based training in HCC documentation, coding accuracy, and reimbursement impact.

What You Will Master: CMS-HCC Risk Adjustment Model (V24 & V28)

RAF Score Calculation and Financial Impact

Chronic Condition Capture & Documentation Review

MEAT Criteria (Monitor, Evaluate, Assess, Treat)

Prospective and Retrospective Risk Adjustment

RADV Audit Readiness & Compliance Standards

Medicare Advantage Coding Guidelines

HCC Gap Analysis & Suspect Condition Identification

Clinical Documentation Improvement (CDI) for HCC

Real-world Redacted Medical Record Analysis

This fellowship focuses not only on assigning ICD-10-CM codes but also on understanding the clinical rationale, documentation validation, and audit defensibility required in risk-adjusted payment environments.

The FIMC-HCC by PMBAUSA LLC is ideal for:

Medical Coders and Auditors

Risk Adjustment Analysts

Revenue Cycle Professionals

Medicare Advantage Consultants

Healthcare Compliance Professionals

Participants gain advanced competency in interpreting provider documentation, identifying chronic condition continuity, preventing overcoding and undercoding risks, and strengthening audit-ready HCC submissions.

As value-based reimbursement continues to expand, professionals trained in HCC Risk Adjustment Coding are positioned for high-growth roles in Medicare Advantage, payer organizations, MSOs, and healthcare consulting firms.

The FIMC-HCC Fellowship serves as a strategic upskilling pathway for coders who want to transition from traditional coding roles to high-level Risk Adjustment and Performance Advisory positions.

Course Objectives

The objective of the FIMC-HCC Fellowship by PMBAUSA LLC is to develop advanced competency in HCC Risk Adjustment Coding, documentation validation, and RAF impact analysis within Medicare Advantage and value-based care models.

By the end of this fellowship, participants will be able to:

  • Explain the CMS-HCC Risk Adjustment Model (V24 & V28) framework

  • Interpret and apply RAF score calculations accurately

  • Identify chronic conditions impacting hierarchical risk categories

  • Apply MEAT criteria to validate documentation support

  • Perform prospective and retrospective Risk Adjustment reviews

  • Conduct HCC gap analysis and suspect condition identification

  • Prevent overcoding, undercoding, and audit vulnerabilities

  • Analyze financial impact of HCC coding on Medicare Advantage plans

  • Ensure compliance with RADV audit requirements

  • Strengthen clinical documentation alignment with HCC capture

  • Interpret provider documentation for defensible coding decisions

  • Develop strategic advisory skills for risk adjustment programs

This fellowship is designed to move professionals beyond ICD-10 code assignment into Risk Adjustment strategy, compliance, and performance leadership.

Table of Contents

1- Introduction to Risk Adjustment Coding

  • Understanding Risk Adjustment:

    • Risk adjustment is a statistical process used in healthcare to adjust payments based on the health status and demographic characteristics of patients.
    • It ensures fair compensation for healthcare providers by accounting for the varying health risks of their patient populations.

  • Purpose of Risk Adjustment:

    • The main goal is to predict future healthcare costs and ensure that providers managing sicker patients are appropriately reimbursed.
    • It supports value-based care models by aligning provider incentives with patient outcomes.

  • Hierarchical Condition Categories (HCC):

    • HCC is a key component of risk adjustment, used by CMS (Centers for Medicare & Medicaid Services) to categorize patient conditions based on ICD-10-CM codes.
    • Each HCC category represents a group of related diagnoses that are likely to have similar healthcare costs.

  • Role of Medical Coders in Risk Adjustment:

    • Coders play a crucial role in accurately capturing patient conditions by selecting the correct ICD-10-CM codes.
    • Proper coding directly impacts risk scores, which influence provider reimbursement and resource allocation.

  • Documentation Requirements:

    • Accurate documentation is essential for risk adjustment coding. Coders must ensure that the medical records thoroughly reflect the patient's conditions.
    • Coders should collaborate with providers to ensure that all relevant diagnoses are documented and coded.

  • Impact on Revenue Cycle Management:

    • Risk adjustment coding directly affects the revenue cycle, influencing reimbursement rates for healthcare providers.
    • Accurate coding helps avoid underpayments and ensures that providers receive appropriate compensation for managing high-risk patients.

  • Compliance and Regulations:

    • Coders must adhere to strict compliance guidelines and regulations when performing risk adjustment coding.
    • Understanding CMS guidelines and avoiding upcoding or undercoding is critical to maintaining compliance.

  • Challenges in Risk Adjustment Coding:

    • Risk adjustment coding can be complex due to the need to accurately capture chronic conditions and other high-risk diagnoses.
    • Continuous education and staying updated on coding guidelines are necessary to navigate the challenges effectively.

  • Benefits of Accurate Risk Adjustment Coding:

    • Proper coding leads to better patient care, as it allows for accurate assessment of patient risk and resource needs.
    • It also supports the financial stability of healthcare organizations by ensuring they are reimbursed for the care they provide.

  • Continuous Learning:

    • The field of risk adjustment coding is dynamic, with frequent updates to coding guidelines and methodologies.
    • Coders should engage in continuous learning and professional development to stay current and excel in this area.

2- Hierarchical Condition Categories (HCC) Coding Fundamentals

HCC Payment

HCC Coding Resources

Frequently Asked Questions

When does the course start and finish?
This course is completely self-paced, so you can begin at any time and set your own pace.
How do I access the course?
Once you sign up, you will receive an email invitation to join the course. You can access the course from any device with a live Internet connection. The course will work on a desktop, laptop, tablet, and smartphone.
What are the advantages of taking this course online?
Online courses provide unparalleled convenience and flexibility. You can take the course anytime and anywhere, on any device you own.
How do I ask questions?
You can email your instructor directly or utilize the course discussion board.
Is FIMC-HCC recognized or endorsed by CMS or any government agency?
No. FIMC-HCC is an independent fellowship program developed and issued by PMBAUSA LLC for professional education and skill development. It is not affiliated with, endorsed by, or recognized by CMS, Medicare, or any federal or state government agency.
Does completion of FIMC-HCC guarantee employment, promotion, or payer approval?
No. Completion of the FIMC-HCC fellowship demonstrates professional training in HCC Risk Adjustment concepts. Employment opportunities, compensation, or payer-related outcomes depend on individual qualifications, experience, employer policies, and market conditions. PMBAUSA LLC does not guarantee placement or specific financial results.

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