As the healthcare landscape evolves, the transition to the CMS-HCC (Hierarchical Condition Category) Model V28 represents a significant shift for health plans. RAAPID, a pioneer in healthcare technology solutions, is at the forefront of supporting health plans in navigating this transition. This blog provides insights into the CMS-HCC Model V28, its implications, and strategies for health plans to effectively adapt to these changes. The CMS-HCC Model V28 emphasizes the importance of accurately coding and assessing patients with multiple chronic conditions to ensure appropriate reimbursement and tailored care.
- Understanding the CMS-HCC Model V28
- Strategic Planning for Health Plans
- New Risk Adjustment Model Version 28 & its Impact
- CMS-HCC Version 28 Impacts Patients
- Beneficiary Risk Scores Influenced by V-28 Risk Adjustment Model
- Key Changes Under V28
- V28 RAF Score Calculation – How it’s Done
- Comparison between V24 to V28
- Challenges Posed by New Risk Adjustment V28 Model
- Conclusion
Understanding the CMS-HCC Model V28
The CMS-HCC Model V28, set to fully transition by 2026, introduces substantial changes in risk adjustment and reimbursement methodologies. This v28 hcc model is more refined, with an expanded number of HCC categories (from 86 to 115), changes in ICD-10-CM to HCC mapping, and adjustments in coefficient values. These changes are based on updated fee-for-service data and aim to more accurately reflect recent utilization, coding, and expenditure patterns in healthcare.
For health plans, this transition is crucial. The v28 medicare advantage model is expected to decrease Medicare Advantage risk scores by 3-8%, which translates to substantial changes in revenue and strategic planning. Health plans must proactively adapt to these changes to maintain financial sustainability and operational efficiency. The cms-hcc risk adjustment model v28 pdf provides detailed information on these changes and their implications.
Strategic Planning for Health Plans
The phased implementation of CMS-HCC Model V28 offers health plans the opportunity for strategic planning. RAAPID’s solutions, with our AI, ML, NLP, and knowledge graph technologies, are ideally suited to assist health plans in this transition. By leveraging our platform, health plans can:
- Accurately assess risk and ensure compliance with regulatory requirements.
- Proactively plan for anticipated changes in revenue and risk scores.
- Minimize operational disruptions and maintain focus on patient care and value-based partnerships.
- Gain a competitive edge by adapting early to the new model’s requirements.
New Risk Adjustment Model Version 28 & its Impact
The changes in CMS-HCC Model V28 will impact RAF (Risk Adjustment Factor) scores significantly. Notably, the model uses a constraining process where related HCCs are given the same coefficients. This could lower RAF scores for many patients, especially those with chronic conditions like diabetes and chronic complications. For this, it means a need for precise identification of HCCs and robust evidence retrieval from medical records.
RAAPID’s cloud-based solutions enable health plans to navigate these complexities by providing accurate chronic condition extraction and risk score calculation, critical for adapting to the V28 model.
Managing two versions will present challenges for providers due to differences between systems. Conditions classified as HCCs in one version may not be in the other. Although a diagnosis might be categorized as an HCC in both versions, the specific HCC and RAF could differ. For instance, diabetes with and without complications carries the same RAF in version 28, whereas a diabetic complication in the v24 hcc model yields a higher RAF than diabetes without complications. Organizations will aim to pinpoint the primary HCCs among their patient base to assess and grasp the possible repercussions of the two model iterations.
As HCC models progress, one aspect that stays consistent is the significance of thoroughly documenting conditions with clinical precision. This precision ensures the intricacies of the patient population are captured and furnishes CMS with coded data for future analysis to inform model recommendations.
The new HCCs are designed to capture more complete and accurate data about the health status of patients with chronic conditions. This will help medical practices better understand their patient’s health needs and provide the care they need to manage their conditions effectively. It will also require medical practices to update their coding practices and risk adjustment strategies, which will require significant time and resources.
Accurate Risk Adjustment with V28
Accurate risk adjustment is crucial for Medicare Advantage plans to receive fair reimbursement for the care they provide to beneficiaries. The v28 risk adjustment model requires healthcare providers to adopt precise coding practices, ensuring that patient data is accurately captured and reflected in the risk adjustment scores. This includes using the latest ICD-10-CM codes, accurately documenting patient conditions, and ensuring that all relevant diagnoses are captured. By doing so, healthcare providers can ensure that their risk adjustment scores truly reflect the health status of their patients, leading to more appropriate reimbursement and better resource allocation.
Strategies for Achieving Accurate Risk Adjustment
To achieve accurate risk adjustment with V28, healthcare providers should:
- Stay up-to-date with the latest coding changes and updates.
- Ensure accurate and specific documentation of patient conditions.
- Use technology to support accurate coding and data capture.
- Regularly review and update patient data to ensure accuracy.
- Provide ongoing education and training to coding staff on V28 requirements.
These strategies are essential for maintaining high standards of data accuracy and ensuring that risk adjustment scores are reflective of the true health status of patients.
Impact of Accurate Risk Adjustment on Patient Care
Accurate risk adjustment has a direct impact on patient care, as it ensures that Medicare Advantage plans receive fair reimbursement for the care they provide. This, in turn, enables plans to invest in quality patient care, including preventive services, chronic disease management, and care coordination. Accurate risk adjustment also helps to identify patients with complex needs, enabling targeted interventions and improved health outcomes. By ensuring that risk scores are accurate, healthcare providers can better allocate resources and provide the necessary care to those who need it most, ultimately reducing healthcare costs and improving early detection of health issues.
CMS-HCC Version 28 Impacts Patients
CMS implemented substantial modifications to the framework of the HCC model in Version 28 (V28), affecting RAF scores for many Medicare Advantage beneficiaries. Nevertheless, CMS acknowledged that the changes in the proposed rule could change beneficiary risk scores with or without a change in the patient’s health status. The proposed model “results in more appropriate relative weights for the HCCs in the model because they reflect more recent utilization, coding and expenditure patterns in FFS Medicare.”
Beneficiary Risk Scores Influenced by V-28 Risk Adjustment Model
The contribution to the RAF score from diabetic disorders will not change regardless of whether the patient has uncomplicated diabetes or complications, as they are assigned the same coefficient under the V28 model.
Example 1: The Complicated Diabetes Patient
Susan: Susan, a 68-year-old woman, has Type 2 diabetes along with peripheral neuropathy and high blood pressure.
V24: In CMS-HCC V24, each of Susan’s conditions would contribute separate HCC codes. This would result in a relatively high overall risk score for her.
V28: V28 focuses on the overall impact of Susan’s diagnosis. The severity of her diabetes complications is prioritized over simply listing each condition separately. While still significant, her risk score may be lower than V24.
The overall impact of the proposed changes on beneficiary (patient) RAF scores will depend on several factors listed below. However, RAF scores in general will likely decline.
Key Changes Under V28
Focus on Severity: V28 emphasizes the severity of medical conditions rather than the presence of numerous diagnoses. A patient with a few very severe conditions could have a higher risk score than someone with many less complex health problems.
Specificity: Many previously accepted diagnosis codes are no longer valid in V28. This puts more focus on accurate and clinically relevant documentation.
Overall Impact: For most beneficiaries, the switch to V28 is expected to result in slightly lower risk scores. However, individuals with very complex or severe conditions may see an increase.
CMS projects that the proposed Part C CMS-HCC model’s impact on MA risk scores in CY 2024 will be -3.12%. This projects $11.0 billion in net savings to the Medicare Trust fund in 2024. Actual (PM) payment amounts are based on multiple additional factors.
The following 2 examples demonstrate the potential impact of the proposed changes on RAF scores (based on disease parameters)
Example 1: Significant negative impact on risk score based on disease coefficients in a Community, Non-Dual, Aged 73-year-old female beneficiary with multiple conditions. Only the disease coefficients for V24 and V28 are shown.
Example 2: John’s Evolving Kidney Disease
John: John is a 72-year-old with a history of chronic kidney disease (CKD). Over the past few years, his kidney function has declined.
V24: In V24, John’s risk score would change as he progressed through different stages of CKD (e.g., Stage III to Stage IV).
V28: V28 groups John’s CKD into broader categories based on severity. If his kidney disease progressed to ESRD requiring dialysis, this would trigger a new HCC category with a significantly higher risk score.
Here is an example showing how the removed codes impact the patient.
Example 3: The Impact of Removed Codes
Martha: Martha is an 80-year-old with mild cognitive impairment and a prior history of protein-calorie malnutrition.
V24: Both conditions generated risk adjustment under V24.
V28: While cognitive impairment is still recognized, protein-calorie malnutrition is among the many codes removed from the HCC model in V28. Therefore, Martha’s risk score would be affected, likely leading to a reduction. It’s worth noting that the dementia HCC code may still apply in certain cases of cognitive impairment.
V28 RAF Score Calculation – How it’s Done
The calculation of the RAF score during the model transition requires using both V24 and V28 models. The first step is calculating risk scores for the V24 and V28 CMS-HCC models. The next step is to calculate the risk score as 33% of the adjusted V28 CMS-HCC model risk score and 67% of the adjusted V24 CMS-HCC model risk score.
Using updated HCCs for calculating risk adjustment scores, this new model will be phased in over the next 3 years, as shown below.
Payment Year (PY) 2024: The 2024 risk scores will be blended, with 67% calculated using the current (2020 or V24) risk adjustment model and 33% calculated using the finalized 2024 (V28) risk adjustment model.
PY Year 2025: For 2025 risk scores, 33% will be calculated using the current (2020 or V24) risk adjustment model, and 67% will be calculated using the finalized 2024 risk adjustment model.
PY 2026: 100% of 2026 risk scores will be calculated using the finalized 2024 (V28) risk adjustment model.
Changes in ICD-10-CM to HCC Mappings
The V28 model introduces significant changes to ICD-10-CM to HCC mappings, with a focus on more accurate and specific coding. The new model includes:
- Fewer ICD-10-CM to HCC mappings, with a focus on more specific and accurate coding.
- Updated fee-for-service data years (including 2018 diagnoses and 2019 expenditures) to calibrate the V28 model.
- A process referred to as constraining, where related HCCs are given the same coefficients.
These changes are designed to improve the accuracy of risk adjustment scores by ensuring that the coding reflects the true severity and complexity of patient conditions. By using the same HCC coefficients for related HCCs, the model aims to provide a more consistent and fair assessment of patient risk, ultimately leading to better resource allocation and patient care.
Comparison between V24 to V28
Below are some of the prime parameters that differentiate cms hcc v24 vs v28:
a). Expansion of payment categories: Payment categories grew from 86 to 115.
b). Reduction in diagnostic codes: The number of diagnostic codes decreased from 9,797 diagnostic codes to 7,770 diagnostic codes, reflecting the addition of 209 codes and the removal of 2,236. These changes were driven by ICD-10 clinical updates and Principle 10 updates.
c). Reorganization of categories: Well-known categories like 107 and 108 are now categorized as 263, 264, and 267, primarily including codes related to atherosclerosis with complications like ulceration or gangrene.
d). Changes in depressive coding:
- Depression, just like vascular, had over 50% of codes removed. Codes are now limited to moderate or severe major depression.
- Mild, unspecified, or in remission, including bipolar in remission, are now nonpayment, and physicians helping create V28 agreed that anyone having a relapse would be reflected with a more severe active disorder.
e). Added diagnostic codes: Notable additions include 20 codes related to benign carcinoid tumors and codes for anorexia and bulimia nervosa, post-polio syndrome, and severe persistent asthma, among others.
Source: CMS
Challenges Posed by New Risk Adjustment V28 Model
Throughout the last ten years, CMS’s ongoing adjustments to Risk Adjustment models, submission procedures, and regulatory frameworks have introduced complexities in some operational areas for health plans. The new CMS-HCC model (V28) launch in 2024 has only heightened concerns. Some industry veterans believe the alterations made to the CMS model in V28 disregarded input from both plans and providers, suggesting a primary objective of mitigating discretionary coding variations. Also, the lack of collaborative engagement in the formulation of V28 prompts inquiries into its capacity to portray patient risk profiles precisely. Moreover, the number of HCC categories increases from 86 to 115 but assigns risk scores to 2,294 fewer codes.
With New Model (V28) Comes New Opportunities
The transition from V24 to V28 within the Medicare Advantage risk adjustment model carries significant implications for both RAF scores and financial outcomes. According to CMS, this transition is anticipated to yield a noteworthy -3.12% impact on MA risk scores by CY 2025, resulting in substantial net savings of $11.0 billion to the Medicare Trust fund in 2024. Furthermore, the new RADV final rule underscores the critical importance of accurately identifying HCCs to determine RAF scores and reimbursement. With adjustments in coefficients and eliminating certain conditions, precise identification of HCCs and robust retrieval of supporting evidence from unstructured medical records have become paramount.
Conclusion
The CMS-HCC Model V28 represents a pivotal change in the risk adjustment landscape, with significant implications for health plans. This model transition requires a deep understanding of the new v28 hcc list and cms-hcc v28 mapping. RAAPID is dedicated to supporting health plans through this transition, providing innovative solutions that enable them to navigate these changes effectively. By partnering with RAAPID, health plans can confidently approach the CMS-HCC Model V28, optimizing their financial outcomes while delivering high-quality care to their members.
Explore RAAPID’s solutions today and ensure your organization is prepared for the CMS-HCC Model V28. Together, we can drive success in the era of value-based healthcare, focusing on improved coding accuracy, payment accuracy, and overall healthcare utilization management.
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