A Comprehensive Guide on HCC Coding Reviews
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Use for DOS on or after Jan 1, 2025
CMS HCC Model V28
| Category/ICD10 | Diagnosis Description | CMS-HCC-V28 | RAF Score | MA Payment |
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Understanding The Importance of HCC V28 in Risk Adjustment.
The CMS-HCC model V28 introduces significant changes to calculating risk adjustment for Medicare Advantage patients.
What is HCC V28?
HCC V28 is the latest version of the Hierarchical Condition Category (HCC) risk adjustment model used by the Centers for Medicare and Medicaid Services (CMS). This model estimates future healthcare costs for Medicare Advantage patients based on their health status and demographic factors. The Risk Adjustment Factor (RAF) score, determined by HCC V28, plays a crucial role in the payment CMS makes to health plans per patient.
Importance of HCC V28
The HCC risk adjustment model ensures that Medicare Advantage Organizations (MAOs) receive appropriate compensation for patients with varying levels of health complexity. Higher payments are made for patients with multiple or severe conditions, reflected in higher RAF scores. This model helps MAOs manage resources effectively and provide quality care to patients with significant health needs.
Key Changes in CMS HCC Model V28
The CMS HCC model V28 incorporates several critical updates by the time:
Increased HCC Categories:
The number of HCC categories has risen from 86 to 115, allowing for a more detailed classification of health conditions.Reduced HCC Codes:
The total HCC dx codes have decreased from 9797 to 7770, streamlining the coding process.Code Updates:
Approximately 2294 codes have been deleted, and 268 new codes have been added, ensuring the model reflects current medical practices.Renumbering and Category Changes:
HCC RAF categories have been renumbered and modified to better align with contemporary diagnostic criteria.Adjusted Coefficient Values:
Changes to the HCC coefficient values (risk scores) ensure more accurate risk adjustment.Constraining in HCC V28
Constraining is used in HCC V28 to reclassify HCC mappings, where related HCCs are assigned the same coefficients. This approach helps standardize risk scores for associated conditions. For example, diabetic disorders now contribute the same to the RAF score, regardless of whether the patient has uncomplicated diabetes or diabetes with complications. This leads to more accurate and fair risk adjustments.
RAF Score Calculation
During the transition to HCC V28, the RAF score is calculated using the HCC V24 and HCC V28 models. For 2024, the final risk score is determined by blending 33% of the HCC V28 and 67% of the V24 scores.
Managing two versions of HCC models can be challenging. Health plans and providers should focus on specific documentation and accurate HCC coding to effectively manage their HCC risk adjustment processes. Identifying the top HCCs among patients will help understand the impact of the two model versions and adapt strategies accordingly.
Introducing the RAF Score Calculator Tool
To assist with the transition to HCC V28, we introduce the RAF Score Calculator Tool. This tool simplifies the calculation of RAF scores by incorporating both HCC V24 and HCC V28 models. This tool allows healthcare providers and MAOs to ensure accurate and efficient risk adjustment, facilitating a smooth transition to the CMS HCC V28.
You can use this tool easily at our website www.rafscorecalculator.com
Suggested Pages
Understanding the CMS HCC Risk Adjustment Model and its Significance
The Role of RAF Score Calculator in Achieving Sustainable Success in Risk Adjustment
Understanding HCC Risk Adjustment Coding (RA) in Healthcare Industry
