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Continued Discussion Surrounding RA/HCC V28 Changes

Let’s continue the discussion surrounding the RA/HCC V28 changes which are effective January 1, 2024. 

First, a reminder that the underlying concept of RA/HCCs does not change with the 2024 update.  CMS’s risk adjustment model is designed to properly recognize each patient’s disease burden and estimate future health care cost for beneficiaries. 

In this prospective system, each HCC category is in an acuity hierarchy of similar categories and a sub-set of ICD-10-CM codes map to an HCC category.  HCC diagnosis coding provides a complete picture of a patient’s level of complexity, and RAF scores assist in predicting health care resource utilization while adjusting costs for patients.

CMS routinely evaluates and adjusts risk adjustment scores as well as HCC categories and the associated ICD-10-CM diagnosis codes.  These changes include 1) HCC category factors increased or decreased; 2) HCC categories removed or added; and 3) ICD-10-CM codes added, removed or remapped. 

As previously noted, the conversion from V24 to V28 of RA/HCC includes a variety of changes as noted below:

We know, CMS uses historical data to revise and update all reimbursement systems, and risk adjustment is no exception. The change in the number of HCCs between CMS-HCC V24 and CMS-HCC V28 are due to a variety of factors that include newly created HCCs, splitting of several existing HCCs, improvements in the clinical specificity of codes in ICD-10-CM and updates in the clinical concepts for some conditions.

Utilization of RA data has resulted in a significant number of diagnoses being deleted from V28 of RA/HCC. The data revealed both clinical and financial justification for the deletion of these diagnoses.  This data includes:

  • The inability of the specific condition to actually predict costs
  • Conditions in which the coefficients were small or insignificant
  • Uncommonly seen conditions
  • Conditions without well-specified diagnostic coding criteria

Conversely, as we would expect, the data also revealed deficiencies in diagnoses that will now be included in V28 of RA/HCCs.

In the next post, we will dive deeper into the V28 changes with a comparison of several different HCC hierarchies between V24 and V28.