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How do the CMS-HCC model changes impact you?

The eagerly anticipated changes to the CMS-HCC model are here. There are some positive and negative impacts that are coming your way.  How you fare is dependent on your population though the model is predicting a 3.32% increase in payments to Medicare Advantage plans over three years. As a result, shoring up your risk adjustment program is more important than ever to ensure financial and quality sustainability.

Here’s a quick summary of the changes:

2024 is the first year that ICD-10-CM will be used to create the HCC groupings. These changes will help to bring together ICD-10-CM coding language and current clinical language. It can be challenging when providers clinical language does not correspond with ICD-10-CM language causing a gap in communications. 

Some of the key Final rule changes:

  • The use of more current claims data- recalibration updates the data year to 2018 diagnoses and 2019 expenditures from 2014 diagnoses and 2015 expenditures. The denominator year used to calculate risk scores will update to 2020 from the current 2015.
  • Newly created HCCs- In the proposed 2024 CMS-HCC model, 115 HCCs will qualify for payment, up from the current 86. This change is due to improvements in clinical specificity of codes within ICD-10-CM; updates in clinical concepts for some conditions; newly created HCCs; and the splitting of several existing HCCs.
  • More clinical specificity of codes within ICD-10-CM continues with each update and allow more specificity for HCC diagnoses. 
  • Elimination of diagnoses determined to subject to coding variation or inappropriate coding i.e., HCC 47 – Protein-calorie malnutrition, HCC 230 – Angina Pectoris, HCC 265 -Atherosclerosis of Arteries of the Extremities, with Intermittent Claudication

Because of the hierarchical groupings, these changes create even more urgency in accurate and complete ICD-10-CM coding in 2024 and beyond. The importance of paying particular attention to specificity of diagnosis ensuring that every diagnosis reported meets the MEAT (Monitor, Evaluate, Assess, Treat) requirements will increase with this change. 

Other significant changes in risk scores with this ruling include:

DiagnosisRisk Score 2023Proposed Score 2024
Diabetes with Chronic Complications0.3020.166
Morbid Obesity0.250.186
Breast, Prostate and other cancers0.150.186
Congestive heart failure0.3310.360
Cancer metastatic to other organs2.6594.209
Cancer metastatic to bone2.6592.341

Whether these changes will have a positive or negative impact upon your risk scores is dependent on your population. However, due to the prediction of lowering risk scores with some chronic conditions, it’s important to begin to prepare and educate around these changes. With many health systems recapture rates below the best practice goal of 85%, there is room for improvement in most health systems.  Shoring up your program will help reduce the impact of these changes.

Talk to our experts to help start or optimize your risk adjustment program. Whether you can take a small step or a big leap, we bring pragmatic solutions to meet you where you are to see progress and ROI quickly.