Part-1

Demographic Rate Adjustments, HCC grouping changes, and details on HCC groupings 1 to 7

Table of Contents

• i. Demographic Rate changes
• ii. HCC number changes and groupings

1. 1) Infectious Disease Grouping
2. 2) Neoplasm disease group
3. 3) Diabetes Disease Group
4. 4) Metabolic disease group
5. 5) Liver disease group
6. 6) Gastrointestinal Disease Group
7. 7) Musculoskeletal Disease Group

Demographic Rate changes

Each patient in the HCC model is given a base risk adjustment number based on:

1. 1. Sex and Age
2. 2. Disability status
3. 3. If they are fully or partially dual eligible (for Medicare/Medicaid)

The changes in demographic rates from V24 to 28 are expected to drop on average across all categories by 1.65% in females, and 7.43% in males. Most groups had between a 1% – 5% decrease, but it is worth noting that the biggest changes seen were in the disabled populations (See graph below for average change across all ages per subgroup)

• -Community non-dual eligible males had a -7.11% change across all ages
• -Fully dual-eligible males had a -9.60% decrease across all ages
• -Partially dual-eligible males had a -7.11% change across all ages
• -The only grouping whose average score increased was the partially dual-eligible females with a 3.29% average increase

HCC number changes and groupings

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 and allowed for more specificity in charting and grouping. The total number of HCCs increased from 86 to 115 while the total number of codes that map to an HCC diagnosis decreased from 9,797 codes to 7,770. CMS separates the 115 HCCs into 26 groupings of conditions, and conditional hierarchies are contained in these groupings as well. Over the next couple of weeks, we will discuss the changes from V24 to V28, going into detail about 7 categories a week.

1) Infectious Disease Grouping

This grouping was largely unchanged. V24 HCC 1 (HIV/AIDS), and V24 HCC 6 (Opportunistic infections) are completely unchanged when moved to their V28 counterparts. V24 HCC 2 (Sepsis) has had two codes removed

• - T81.12XA – Postprocedural septic shock – initial
• - T81.44XA – Sepsis following a procedure – initial encounter

2) Neoplasm disease group

The codes in each V24 HCC were separated into multiple groups. V24 HCC 8 (Metastatic Cancer and Acute Leukemia) was split into 3 different V28 HCCs, V24 HCC 9 (Lung and Other Severe Cancers) was separated into 4 V28 HCCs, V24 HCC 10 (Lymphoma and Other Cancers) was divided into 7 V28 HCCs, V24 HCC 11(Colorectal, Bladder, and Other Cancers) was regrouped into 3 V28 HCCs and lastly, V24 HCC 12 (Breast, Prostate, and Other Cancers and Tumors) was split into 2 different V28 HCCs. No codes were eliminated from these HCCs, however, due to the reclassification of the codes, each ICD-10 will have had a change in its RAF. See below for the details of the changes

V24 HCC 8 had its codes divided into V28 HCC 17 (Cancer Metastatic to Lung, Liver, Brain, and Other Organs; Acute Myeloid Leukemia Except Promyelocytic), HCC 18 (Cancer Metastatic to Bone, Other and Unspecified Metastatic Cancer; Acute Leukemia Except Myeloid) and HCC 22 (Bladder, Colorectal, and Other Cancers)

• -The codes moving to HCC 17 received an average RAF increase of 1.422 among all populations
• -The codes moving to HCC 18 received an average RAF decrease of 0.274 among all populations
• -The codes moving to HCC 22 received an average RAF decrease of 2.262 among all populations

V24 HCC 9 had its codes divided into V28 HCV 17, HCC 19 (Myelodysplastic Syndromes, Multiple Myeloma, and Other Cancers), HCC 20 (Lung and Other Severe Cancers), and HCC 22

• -The codes moving to HCC 17 received an average RAF increase of 3.093 among all populations
• -The codes moving to HCC 19 received an average RAF increase of 0.710 among all populations
• -The codes moving to HCC 20 received an average RAF increase of 0.151 among all populations
• -The codes moving to HCC 22 received an average RAF decrease of 0.591 among all populations

V24 HCC 10 had its codes divided between V28 HCC 17, HCC 18, HCC 19, HCC 20, HCC 21 (Lymphoma and Other Cancers), HCC 22, HCC 23 (Prostate, Breast, and Other Cancers and Tumors)

• -The codes moving to HCC 17 received an average RAF increase of 3.376 among all populations
• -The codes moving to HCC 18 received an average RAF increase of 1.681 among all populations
• -The codes moving to HCC 20 received an average RAF increase of 0.435 among all populations
• -The codes moving to HCC 21 received an average RAF decrease of 0.046 among all populations
• -The codes moving to HCC 22 received an average RAF decrease of 0.308 among all populations
• -The codes moving to HCC 23 received an average RAF decrease of 0.476 among all populations

V24 HCC 11 had its codes divided between V28 HCC 20, 21, and 22

• -The codes moving to HCC 20 received an average RAF increase of 0.788 among all populations
• -The codes moving to HCC 21 received an average RAF increase of 0.307 among all populations
• -The codes moving to HCC 22 received an average RAF increase of 0.046 among all populations

V24 HCC 12 had its coded split between V28 HCC 21 and 23

• -The codes moving to HCC 21 received an average RAF increase of 0.464 among all populations
• -The codes moving to HCC 23 received an average RAF increase of 0.034 among all populations

3) Diabetes Disease Group

Multiple changes have happened in this grouping. First, V28 HCC 35 (Pancreas Transplant Status) has been added to this grouping at the top of the hierarchy and will absorb any diabetic codes when present. Next, all forms of drug or chemically-induced diabetes (E09) have been removed from the risk adjustment model. Diabetes Mellitus without complication has had its RAF increased by an average of 0.077 across all populations but Diabetes Mellitus with acute or chronic complications has had a RAF decrease by an average of 0.16. Details of the changes are below

V24 HCC 17 (Diabetes with Acute Complications) had all of its codes moved to V28 HCC 36 (Diabetes with Severe Acute Complications) with the exception of drug or chemical-induced diabetes which were removed from the model in every V24 HCC

• -These codes received a RAF decrease of 0.160

V24 HCC 18 (Diabetes with Severe Acute Complications) had all of its codes moved to V28 HCC 37 (Diabetes with Chronic Complications)

• -These codes received a RAF decrease of 0.160
• -The codes for hypo and hyperglycemia were moved to V28 HCC 38 (Diabetes with Glycemic, Unspecified, or No Complications) which resulted in a RAF decrease of 0.160

V24 HCC 19 (Diabetes without Complication) had all of its codes moved to V28 HCC 38

• -These codes received a RAF increase of 0.077

4) Metabolic Disease Group

This grouping has had a large change. First, V24 HCC 21 (Protein-Calorie Malnutrition), and all codes in that HCC were removed from the model. V24 HCC 22 (Morbid Obesity) is staying but will decrease by 0.077 on average across all populations. V24 HCC 23 (Other Endocrine Disorders) has had the most alterations (see details below).

V24 HCC 21 has had all codes removed from the model

V24 HCC 22 had all of its codes moved to V28 HCC 48 (Morbid Obesity) with an RAF decrease of 0.077

V24 HCC 23 had several commonly coded conditions removed from the model and the rest of the codes split between V28 HCC 21, HCC 49 (Specified Lysosomal Storage Disorders), HCC 50 (Amyloidosis, Porphyria, and Other Specified Metabolic Disorders), HCC 51(Addison’s and Cushing’s Diseases, Acromegaly, and Other Specified Endocrine Disorders), HCC 115 (Specified Immunodeficiencies and White Blood Cell Disorders), and HCC 202 (Coma, Brain Compression/Anoxic Damage)

• -Commonly coded conditions that were removed from the model include all forms of hyperparathyroidism, all forms of hyperaldosteronism, and drug-induced adrenocortical insufficiency
• -Only one code (C88.0, Waldenstrom macroglobulinemia) was moved to V28 HCC 21 and received a RAF increase of 0.379
• -The codes moving to V28 HCC 49 include Pompe disease, Gaucher disease, and mucopolysaccharidosis

• All codes moving to V28 HCC 49 received a RAF increase of 6.955.
• -The codes moving to V28 HCC 50 include Lesch-Nyhan syndrome and various forms of amyloidosis and porphyria

• All codes moving to V28 HCC 50 received a RAF increase of 0.377
• -The codes moving to V28 HCC 51 include MEN syndrome, Cushing disease, and adrenocortical insufficiency

• All codes moving to V28 HCC 51 received a RAF increase of 0.256
• -Only one code (D84.1, Defects in the complement system) was moved to HCC 115 and received a RAF increase of 0.256
• -Only one code (E03.5, Myxedema coma) was moved to V28 HCC 202 and received a RAF increase of 0.177

5) Liver Disease Group

Two new HCCs were added to this grouping, one at the top of the hierarchies, HCC 62 (Liver Transplant Status/Complications), and one at the bottom, HCC 68 (Cholangitis and Obstruction of Bile Duct Without Gallstones). Only minor changes occurred in the HCCs between V24 and V28, with the exception of a few codes being removed from the model. The details of the changes are as follows:

V24 HCC 27(End-Stage Liver Disease) had all of its codes moved to V28 HCC 63 (Chronic Liver Failure/End-Stage Liver Disorders) with the exception of 2 codes being removed from the model, K71.11 (Toxic liver disease with hepatic necrosis, with coma) and K72.01 (Acute and subacute hepatic failure with coma)

• -Codes moving to V28 HCC 63 will have a RAF increase of 0.082

V24 HCC 28 (Cirrhosis of Liver) had most of its codes moved to V28 HCC 64 (Cirrhosis of Liver) resulting in a RAF increase of 0.027 with a few exceptions

• -One code (K70.40, Alcoholic hepatic failure without coma) was moved to HCC 63 with a RAF increase of 0.675
• -Two codes (K74.3 and K74.5 for primary and unspecified biliary cirrhosis) were moved to V28 HCC 68 (Cholangitis and Obstruction of Bile Duct Without Gallstones) with a RAF decrease of 0.058
• -Two codes (K70.9 Alcoholic liver disease unspecified and K70.41 Alcoholic hepatic failure with coma) were removed from the model

V24 HCC 29 (Chronic Hepatitis) had all of its codes moved to V28 HCC 65 (Chronic Hepatitis) with a RAF decrease of 0.019

6) Gastrointestinal Disease Group

The major changes in this grouping are that one new HCC was added to this group, V28 HCC 77 (Intestine Transplant Status/Complications) at the top of the hierarchy, and the V24 HCC 35 (Inflammatory Bowel Disease) has been split into separate HCCs for Crohn’s disease and one for ulcerative colitis. Full details are as follows:

V24 HCC 33 (Intestinal Obstruction/Perforation) had all of its codes moved to V28 HCC 78 (Intestinal Obstruction/Perforation) with a RAF increase of 0.109

V24 HCC 34 (Chronic Pancreatitis) had all of its codes moved to V28 HCC 79 (Chronic Pancreatitis) with a RAF increase of 0.077

V24 HCC 35 had its codes split between V28 HCC 80 (Crohn’s Disease (Regional Enteritis)) with a RAF increase of 0.156, and V28 HCC 81 (Ulcerative Colitis) with a RAF decrease of 0.169

7) Musculoskeletal Disease Group

The most significant change in this grouping is the addition of V28 HCC 94 (Systemic Lupus Erythematosus and Other Specified Systemic Connective Tissue Disorders) at the bottom of the hierarchy. Full details are:

V24 HCC 39 (Bone/Joint/Muscle Infections/Necrosis) had most of its codes moved to V28 HCC 92 (Bone/Joint/Muscle/Severe Soft Tissue Infections/Necrosis) with a RAF increase of 0.061

• -An important exception to this is that 44 codes used to document osteonecrosis due to drugs were removed from the model

V24 HCC 40 (Rheumatoid Arthritis and Inflammatory Connective Tissue Disease) had most of its codes moved to V28 HCC 93 (Rheumatoid Arthritis and Other Specified Inflammatory Rheumatic Disorders) with a RAF increase of 0.084, with a few exceptions

• -Codes related to Reiter’s disease, Postrheumatic arthropathy, Giant cell arteritis, and Systemic Lupus Erythematosus were instead moved to V28 HCC 94 with a RAF decrease of 0.114
• -Codes used Sjogren’s disease, polymyalgia rheumatica, and various forms of spondylopathies were removed from the model