Widespread changes to the CMS risk adjustment model are coming in 2024. Although the final details, the anticipated impact of the changes, and what it will mean for risk adjustment are yet to be seen, we wanted to give you some insight into the details of these proposed changes.
Disease + disease interaction modifiers is another variable impacted by v28. (For example, if a patient is coded with both diabetes and CHF, an additional modifier is added to the score). Although HCCs were rearranged into new categories, all of the interaction categories from v24 are still present in v28, with one exception: immune disorders + cancer. The interaction of immune disorders and cancer traditionally added an additional RAF of 0.6-0.8 to each patient.
Looking at the values of the interaction categories, the value of most groups decreased by 12% – 70%. Notably, two particular groupings had substantial increases and deviated from the other trends. These are the interaction of CHF and diabetes and the interaction between CHF and arrhythmias, both in partially dual-eligible aged populations, with an increase of 31% and 25%, respectively.
The v24 model of managed care used ICD-9 codes as its basis for HCC categorization. CMS has now transitioned to ICD-10 as its reference, allowing for more specificity in charting and grouping. In v28, the total number of HCCs increases from 86 to 115, while the number of codes that map to an HCC diagnosis decreases from 9,797 to 7,770. CMS separates the 115 HCCs into 26 groupings of conditions, and conditional hierarchies are also contained in these groupings.
The main call-outs on deletions include:
It is no secret that a wide variation of HCC coding patterns exist among clinical groups engaged in the Medicare Advantage program. v28 will eliminate many of the diagnoses that are found through careful screening or loosely defined clinical judgment.
Regardless of where you sit philosophically on the debate, the following will undoubtedly occur: