DETAILS ON THE CHANGES BETWEEN
HCC MODEL V24 AND V28
Widespread changes are coming in 2024 for the CMS risk adjustment model. Although the final details, the impact of the changes, and what that means for risk adjustment are yet to be seen, over the next couple of weeks, DoctusTech will highlight in depth the proposed impact of:
- Changes to demographic rates
- Disease interaction modifiers
- Payment HCC counts
- ICD10 prevalence rate changes
In each edition of the 4 part series, we will highlight a number of HCC groupings and notable changes for each HCC
Part 1: Demographic Rate Adjustments, HCC grouping changes, and details on HCC groupings 1 to 7
Demographic Rate changes
Each patient in the HCC model is given a base risk adjustment number based on:
-
- Sex and Age
- Disability status
- 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 population
DoctusTech is helping Value-Based Care organizations evaluate their RAF score in the new v28 model. Do you want to know what your organization's RAF score will look like in the new v28 model? Contact us for a detailed impact assessment analytic report. Click the Button Below.
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