June 1, 2023
The Centers for Medicare and Medicaid Services (CMS) uses Hierarchical Condition Category (HCC) risk adjustment models to estimate future healthcare costs for Medicare Advantage beneficiaries based on disease burden and demographic factors.
HCC model V28 was recently finalized by CMS and will begin to phase out the V24 model in 2024. V28 reflects the detail and specificity of ICD-10-CM, which has been in use since 2015. The new model will be phased in over a three-year period, with a blend of 33% for the V28 model and 67% for the V24 model for 2023 dates of service. V28 will be used at 67% for 2024 dates of service and fully phased in at 100% for 2025 dates of service.
The changes to V28 are significant, including:
- Re-numbering and changing HCC categories
- Removal of 2,294 ICD-10-CM codes that no longer map to an HCC
- Significant diagnoses removed from model V28 include:
- Acute kidney failure
- Angina pectoris
- Atherosclerosis of the extremities (PVD)
- Protein calorie malnutrition
- Amputation of toe
- 268 new diagnosis codes mapped to HCCs
- Significant diagnoses added to model V28 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
- An increase in HCCs from 86 in model V24 to 115 in model V28
Specificity of documentation and diagnostic coding have always been essential for accurate risk adjustment. HCC model V28 will require even greater specificity in documentation and code assignment to ensure that the true level of your Medicare Advantage patients’ illness severity is captured.
You may find the following resources helpful:
For more information on best practices for visit documentation and coding, email ProviderClinicalConsulting@premera.com.