Part-4

Raw RAF adjustment modifiers and details on HCC groupings 21 to 26

In the previous 3 Parts, we focused on the changes in demographic rates, the disease + disease interaction modifiers, and the differences in the multiple HCC modifiers. In this final Part, we will examine the changes in the raw RAF adjustments modifiers.

Raw RAF Adjusters

After a patient’s total RAF is calculated, it undergoes two further calculations. First is the normalization ratio calculation. CMS creates this number by looking at the average cost of care and health status of fee-for-service patients over a 5-year period. Once an average RAF is determined from this data, they calculate what number needs to be multiplied by that value to equal 1.0. This number is the ‘normalization ratio.’ The ratio is then divided by the patient's raw RAF score to ‘normalize’ the average health status of a patient. Previously, this number was 1.127, meaning a patient with a total RAF of 3.2 would only be counted as if they had 2.84. The v28 2024 proposed normalization ratio is 1.015. Using the new ratio, the same total RAF of 3.2 will be calculated as 3.15. This means that every patient’s final RAF will be around 10% higher.

The last calculation that is performed takes place after normalization. This calculation is referred to as the “MA coding adjustment.” This is a percent decrease in RAF that is added to compensate for the difference in coding practices between risk adjustment coders and fee-for-service coders. This percentage has maintained at 5.9% for some time and is not proposed to change in v28.

HCC number changes and groupings part 4 of 4

In Part 3 of the 4-part series, we covered the HCCs in the groupings for Heart, Cerebrovascular, Lung, Eye, and Kidney Diseases. In this Part 4, we will cover the last 6 groupings, from Skin Diseases to Openings.

21) Skin Disease Group

The largest change between V24 and V28 is the splitting of the codes in V24 HCC 161 (Chronic Ulcer of Skin, Except Pressure) into different V28 HCCs based on ulcer depth. Another change is the addition of a new V28 HCC 387 (Pemphigus, Pemphigoid, and Other Specified Autoimmune Skin Disorders) with all new codes added to the model. Full details are as follows:

V24 HCC 157

• –V24 HCC 157(Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone) had all of its codes moved to V28 HCC 379 (Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone) with an increase in RAF of 0.041.
• –V24 HCC 158 (Pressure Ulcer of Skin with Full Thickness Skin Loss) had all of its codes moved to V28 HCC 381 (Pressure Ulcer of Skin with Full Thickness Skin Loss) with a decrease in RAF of 0.043.
• –V24 HCC 159 (Pressure Ulcer of Skin with Partial Thickness Skin Loss) had all of its codes moved to V28 HCC 382 (Pressure Ulcer of Skin with Partial Thickness Skin Loss) with an increase in RAF of 0.249.
• –V24 HCC 161 (Chronic Ulcer of Skin, Except Pressure) had two codes removed from the model, and the rest split between V28 HCC 380 (Chronic Ulcer of Skin, Except Pressure, Through to Bone or Muscle) and V28 HCC 383 (Chronic Ulcer of Skin, Except Pressure, Not Specified as Through to Bone or Muscle).
• –Codes moving to V28 HCC 380 included the codes for non-pressure chronic ulcers with muscle or bone involvement. These codes had an increase in RAF of 0.670.
• –Codes moving to V28 HCC 383 included codes for diabetes with ulcer, atherosclerosis of arteries and grafts with ulcer, and non-pressure chronic ulcers with skin or fat layer involvement. These codes received an increase in RAF of 0.127.
• –The two codes that were removed were for drug or chemical-induced diabetes with ulcer.

TV24 HCC 162 (Severe Skin Burn or Condition) had most of its codes moved to V28 HCC 385 (Severe Skin Burn) with an increase in RAF of 0.685.

• –The exceptions to this were the removal of codes for Stevens-Johnsons syndrome, epidermolysis bullosa and toxic epidermal necrolysis from the model.

V28 HCC 387 is made up entirely of codes that were not HCCs in V24. This includes codes for sarcoidosis of the skin, pemphigus and pemphigoid skin conditions, and pyoderma gangrenosum.

22) Injury Disease Group

The major change in V28 for this grouping is the splitting of head injuries into different HCCs based on the length of loss of consciousness. The HCC for amputations had a few codes get moved or dropped as well, but for the most part this grouping is unchanged. Details are:

V24 HCC 166 (Severe Head Injury) had all of its codes moved to V28 HCC 397 (Major Head Injury with Loss of Consciousness > 1 Hour) with a decrease in RAF of 0.195

V24 HCC 167 (Major Head Injury) had its most of its codes divided between V28 HCC 398 (Major Head Injury with Loss of Consciousness < 1 Hour or Unspecified) and V28 HCC 399 (Major Head Injury without Loss of Consciousness) with the rest being removed from the model.

• –Codes moving to V28 HCC 389 include codes for the initial encounter of a major head injury where the loss of consciousness was less than 1 hr or unspecified. These codes had an increase in RAF of 0.118.
• –Codes moving to V28 HCC 399 include codes for initial encounters for skull fractures in addition to major head injuries without loss of consciousness. These codes had an increase in RAF of 0.118.
• –Codes that were removed from the model are the codes for sequela encounters for skull fractures and all types of severe or major head injuries.

V24 HCC 169 (Vertebral Fractures without Spinal Cord Injury) had all of its codes moved to V28 HCC 401 (Vertebral Fractures without Spinal Cord Injury) with an increase in RAF of 0.109.

V24 HCC 170 (Hip Fracture/Dislocation) had all of its codes moved to V28 HCC 402 (Hip Fracture/Dislocation) with an increase in RAF of 0.146.

V24 HCC 173 (Traumatic Amputations and Complications) had most of its codes moved to V28 HCC 405 (Traumatic Amputations and Complications) with an increase in RAF of 0.446. Exceptions are:

• –The code for initial encounter of traumatic Shock was moved to V28 HCC 2 (Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock) with a RAF increase of 0.387.
• –Two codes used for the initial encounter for air or fat embolism were moved to V28 HCC 267 (Deep Vein Thrombosis and Pulmonary Embolism) with an increase in RAF of 0.182.
• –Codes that were removed from the model include codes relating to amputation of toes, compartment syndrome, and unspecified early complications of trauma.

23) Complications Disease Group

This group had only one V24 HCC in it, HCC 176 (Complications of Specified Implanted Device or Graft). The V28 model currently has no HCCs in the grouping and V24 HCC 176 had all of its codes removed.

24) Amputation Disease Group

This grouping only involves one HCC in both V24 and V28 models. V24 HCC 189 (Amputation Status, Lower Limb/Amputation Complications) had most of its codes removed from the model with a small portion going to V28 HCC 409 (Amputation Status, Lower Limb/Amputation Complications). vf

• –Codes moving to V28 HCC 409 includes codes for encounters for fitting for an artificial leg, the acquired absence of foot, ankle, and leg above and below the knee, complications of an amputation stump such as neuroma, infection, or necrosis, and codes for phantom limb syndrome.
• –Codes moving to V28 HCC 49 had an increase in RAF of 0.004

25) Transplant Disease Group

This grouping has only 1 HCC in both V24 and V28 models but the content of those HCCs has changed. V24 HCC 186 (Major Organ Transplant or Replacement Status) had most of its codes moved to the grouping that each organ belongs to. The V24 HCC 454 (Stem Cell, Including Bone Marrow, Transplant Status/Complications) is used for non-solid organ transplants. Details are:

V24 HCC 186 had codes moved by organ system:

• –Codes relating to pancreas transplants were moved to V28 HCC 35 (Pancreas Transplant Status) with an increase in RAF of 0.661.
• –Codes involving liver transplants were moved to V28 HCC 62 (Liver Transplant Status/Complications) with a decrease in RAF of 0.308.
• –Codes for intestine transplants were moved to V28 HCC 77 (Intestine Transplant Status/Complications) with an increase in RAF of 4.138.
• –Codes for both the transplant of the heart alone or heart and lung together were moved to V28 HCC 221 (Heart Transplant Status/Complications) with an increase in RAF of 0.596.
• –Codes for heart assist device and artificial heart were moved to V28 HCC 223 (Heart Assist Device/Artificial Heart) with an increase in RAF of 3.835
• –Codes relating to lung transplants were moved to V28 HCC 276 (Lung Transplant Status/Complications) with an increase in RAF of 1.489.
• –Codes for involving bone marrow or stem cell transplants moved to the new V28 HCC 454 with an increase in RAF of 0.215.

26) Openings Disease Group

This grouping was a direct V24 to V28 conversion with all codes in V25 HCC 188 (Artificial Openings for Feeding or Elimination) moving to V28 HCC 463 (Artificial Openings for Feeding or Elimination) with an increase in RAF of 0.125.