Note from the ACDIS Interim Director: A breakdown of CMS’s 2024 HCC proposed changes

by Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC

Medicare released proposed changes to the CMS-HCC Risk Adjustment Model for payment year 2024 in early February, with a public comment period ending the first week in March. The proposed changes (Model V28) would make significant changes to the existing V24. V24 was structured using the ICD-9-CM codes and, although translated to ICD-10-CM, did not provide the granularity we are now able to with code assignment. This change means that more specificity in code assignment will be required in a number of condition categories.

The proposal increases the number of payment HCCs by 29, with a total of 115 payment HCCs. These 115 HCCs have been renumbered, and new names have been applied to many groupings. Within the methodology, 268 new codes have been identified, but in total V28 demonstrates a reduction of 2,027 diagnoses codes that provide risk adjustment within the present version.

CMS stated that the rationale used to remove diagnoses considered the following:

• The inability of the condition to actually predict costs
• The conditions in which the coefficients were small or thought to be insignificant
• The conditions that are uncommonly seen
• The conditions without “well specified” diagnostic coding criteria

Significant diagnoses that are identified to be eliminated include:

• Acute kidney failure
• Angina pectoris
• Atherosclerosis of the extremities
• Protein calorie malnutrition
• Amputation of toe

Significant diagnoses that are proposed to be added include:

• Anorexia nervosa, bulimia nervosa
• Severe, persistent asthma
• Malignant pleural effusion
• Alcoholic hepatitis with and without ascites
• Toxic liver disease with hepatitis
• Primary sclerosing cholangitis
• Other cholangitis
• Obstruction of the bile duct
• Malignant ascites

The relative factors have also been adjusted. One significant change in the hierarchy related to hierarchy for diabetes (V28: HCC 35, 36, 37, 38). This hierarchy now has four levels, with HCC 35 classifying transplant of the pancreas followed by the HCCs reflecting:

• Diabetes with severe acute complications
• Diabetes with chronic complications
• Diabetes with glycemic, unspecified or no complications

HCCs 36, 37, and 38 offer the same relative factor or impact to patient’s risk score. Presently, HCC 17, diabetes with acute complications, offers a higher impact than HHCs 18 and 19, classifying diabetes with chronic or no complications.

As noted above with HCC 35, classifying transplant of the pancreas, the proposed changes no longer offer a separate hierarchy for solid organ transplants. Although these codes are planned to still offer impact, they are incorporated into hierarchies within their specific body systems. For example, proposed HCC 276, lung transplant status/complications, lies at the top of a hierarchy encompassing chronic lung disease to include a new category for severe persistent asthma.

This release also acknowledges that patient’s beneficiary scores will change because of this proposal, even without a significant change in health status. The conclusion is that the new version will provide more accurate relative weights and risk scores, as they are based upon more recent utilization, coding, and expenditure patterns. Organizations will eagerly await the release of the final rule to better understand the potential impact.

For more information, go to: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Announcements-and-Documents

Editor’s note: Prescott is the interim director for ACDIS and director of CDI education for HCPro, based in Middleton, Massachusetts. Contact her at lprescott@acdis.org. The advanced notice can be reviewed in its entirety here.