2024 HCC Changes: Understanding the Impact on Healthcare Providers and Medical Coders
2024 HCC Changes: Understanding the Impact on Healthcare Providers and Medical Coders
On March 31, 2023, Centers for Medicare & Medicaid Services (CMS) issued the Announcement of Calendar Year (CY) 2024 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. This announcement finalized the transition to a revised risk adjustment model known as the 2024 CMS-HCC risk adjustment model, Version 28 (V28).
CMS is implementing a policy to consistently apply the V28 risk adjustment model in the Shared Savings Program, meaning the same CMS-HCC risk adjustment model used in the performance year will be applied to all benchmark years when calculating prospective HCC risk scores. This policy is effective for agreement periods starting on January 1, 2024, and subsequent years, following a three-year phase-in aligned with the Medicare Advantage transition to the revised 2024 CMS-HCC risk adjustment model (V28). Specifically, for the performance year 2024, the model used will be a blend of 67% of the current 2020 CMS-HCC risk adjustment model (Version 24) and 33% of V28.
Understanding the 2024 HCC Changes
The 2024 version brings significant modifications to the Hierarchical Condition Category (HCC) codes compared to the 2020 version. The key changes include an increase in payment HCCs from 86 to 115, showcasing a more detailed classification of health conditions for risk adjustment. Additionally, the number of ICD-10-CM diagnosis codes mapped to an HCC for payment has decreased from 9,797 in 2020 to 7,770 in 2024, indicating a more focused approach to code mapping.
The alterations within specific disease groups are outlined below:
- Infectious Disease Group:
- Both versions have 3 HCCs, but the specific conditions covered differ.
- Neoplasm Disease Group:
- The 2024 version has expanded to 7 HCCs, covering a broader range of cancer types.
- Diabetes Disease Group:
- The 2024 version has an additional HCC (4 in total), including one for pancreas transplant status.
- Metabolic Disease Group:
- The 2024 version has expanded to 4 HCCs, covering additional metabolic disorders.
- Liver Disease Group:
- The 2024 version has expanded to 5 HCCs, including one for liver transplant status/complications.
- Gastrointestinal Disease Group:
- The 2024 version has expanded to 5 HCCs, covering intestinal transplant status/complications and specific gastrointestinal disorders.
- Musculoskeletal Disease Group:
- The 2024 version has expanded to 3 HCCs, covering severe soft tissue infections/necrosis and lupus erythematosus.
- Blood Disease Group:
- The 2024 version has expanded to 7 HCCs, covering a broader range of blood disorders.
- Cognitive Disease Group:
- The 2024 version has an additional HCC (3 in total) for mild or unspecified dementia.
- Substance Use Disorder Disease Group:
- The 2024 version has expanded to 5 HCCs, covering additional substance use disorder conditions.
- Psychiatric Disease Group:
- The 2024 version has expanded to 5 HCCs, covering additional psychiatric disorders.
- Spinal Disease Group:
- Both versions have 3 HCCs with no significant changes.
- Neurological Disease Group:
- The 2024 version has expanded to 12 HCCs, covering a broader range of neurological conditions.
- Arrest Disease Group:
- Both versions have 3 HCCs with no significant changes.
- Heart Disease Group:
- The 2024 version has expanded to 10 HCCs, covering heart transplant status/complications and heart assist device/artificial heart.
- Cerebrovascular Disease Group:
- Both versions have 4 HCCs with no significant changes.
- Vascular Disease Group:
- The 2024 version has expanded to 3 HCCs, covering atherosclerosis with ulceration or gangrene.
- Lung Disease Group:
- The 2024 version has expanded to 7 HCCs, covering lung transplant status/complications and additional lung disorders.
- Eye Disease Group:
- The 2024 version has 2 HCCs with no significant changes.
- Kidney Disease Group:
- The 2024 version has 4 HCCs, covering chronic kidney disease stages.
- Skin Disease Group:
- The 2024 version has expanded to 7 HCCs, covering a broader range of skin disorders.
- Injury Disease Group:
- The 2024 version has expanded to 6 HCCs, covering additional injury conditions.
- Complications Disease Group:
- The 2020 version has 1 HCC, while the 2024 version has 0 HCCs in this group.
- Amputation Disease Group:
- Both versions have 1 HCC with no significant changes.
- Transplant Disease Group:
- The 2024 version has 1 additional HCC for stem cell transplant status/complications.
- Openings Disease Group:
- Both versions have 1 HCC with no significant changes.
Decoding the Impact for Providers
The transition to the revised 2024 CMS-HCC risk adjustment model, Version 28 (V28), has implications for healthcare providers, extending beyond the operational dynamics of the Shared Savings Program. The consistent application of V28 across benchmark years, starting from January 1, 2024, necessitates careful documentation and accurate coding practices by healthcare providers. As providers adapt to the three-year phase-in, healthcare organizations will need to ensure that their coding practices align with the nuances of both models to accurately reflect the health risk of their patient population, ultimately influencing the determination of benchmark expenditures in the Shared Savings Program.
With an expanded set of 115 payment HCCs, as opposed to the previous 86, the model demonstrates a nuanced understanding of the diverse health conditions prevalent in the population. The inclusion of new HCCs in disease groups such as Neoplasm, Diabetes, Metabolic Disorders, and Musculoskeletal Diseases reflects a more comprehensive approach to risk stratification.
Notably, the increased granularity in disease categories allows for a more accurate representation of patients’ health statuses, potentially improving the precision of risk scores. This shift aligns with the broader industry trend towards more refined risk adjustment models, promoting a more equitable distribution of resources and ensuring that healthcare entities adequately address the needs of patients with diverse and intricate health conditions.
These updates in the 2024 HCC model have far-reaching implications across various areas of healthcare. Particularly, the Neoplasm Disease Group, now expanded to include seven HCCs, introduces a heightened focus on the diverse manifestations of cancer, acknowledging the distinct challenges posed by different types of malignancies. In the Diabetes Disease Group, the addition of HCC 35 related to Pancreas Transplant Status underscores the significance of organ transplant considerations in diabetes management. Moreover, the Musculoskeletal Disease Group’s inclusion of HCCs specific to Severe Soft Tissue Infections and Lupus Erythematosus reflects a more detailed understanding of musculoskeletal health complexities.
These updates resonate deeply in clinical practice, guiding healthcare providers to address the specific needs of patients with conditions that might have been underrepresented in previous risk assessment models. The ripple effect extends to resource allocation, care planning, and the overall adaptability of healthcare systems to cater to the evolving landscape of patient health risks.
Navigating the 2024 HCC changes can be a daunting task for healthcare providers, especially those who are not well-versed in the nuances of medical coding. With the changes in payment HCCs and the focused approach to code mapping, hospitals need to ensure that their coding practices are accurate, efficient, and consistent. Our coding consultants can provide expert HCC coding support services to hospitals, assisting them in navigating the 2024 HCC changes seamlessly. Through our comprehensive coding services, we can help hospitals ensure compliance with regulations, optimize reimbursements, and improve patient outcomes.
Do your providers need help understanding the recent HCC changes and v28 CMS-HCC risk adjustment model? Fill out the form below to schedule a consultation with one of our experts. We can develop a tailored education plan for your team.
Understanding the Implications for Medical Coding Professionals
The introduction of the 2024 CMS-HCC risk adjustment model poses both challenges and opportunities for medical coders. On the one hand, the expanded set of 115 payment HCCs demands a higher level of specificity in coding and documentation to accurately capture the diverse health conditions covered by the new model.
This necessitates continuous training and education to ensure that coders are well-versed in the latest coding guidelines and can accurately translate the intricacies of patient diagnoses into the new coding framework. However, these challenges also present opportunities for professional growth and specialization among medical coders.
Our education subject matter experts (SMEs) can develop tailored training programs on HCCs to help hospitals ensure that their coding team is equipped with the knowledge and skills required to effectively navigate these changes. Contact our team to create a customized program to meet the specific needs of your organization, helping to improve coding accuracy and minimize any potential compliance risks.
Strategies to Help You Adapt to the HCC Changes: A Practical Approach
To help our clients seamlessly integrate the latest coding guidelines of the 2024 CMS-HCC risk adjustment model, our consulting team is implementing these strategies:
- Engaging medical coders in ongoing education. Staying informed about changes in disease groups, new HCCs, and code modifications is crucial for accurate coding and risk assessment. Healthcare institutions should invest in training programs that familiarize coders with updated guidelines, providing practical scenarios to enhance hands-on skills.
- Investing in comprehensive training for clinicians. Additional education for providers will be instrumental in mitigating potential challenges associated with the expanded set of HCCs. Essential training programs for clinicians, in collaboration with educational institutions or coding experts, should be tailored to address the nuances of the 2024 CMS-HCC risk adjustment model.
- Prioritizing interdisciplinary collaboration and regular communication between coding teams, clinicians, and administrative staff. Regular communication channels facilitate collaboration between all departments, ensuring coding practices align with clinical intricacies. By integrating these guidelines into daily practices, coders contribute significantly to the success of risk adjustment initiatives.
- Integrating technology, such as advanced coding software and AI tools for streamlined workflows, is crucial. To optimize workflows and maintain compliance, decision-makers should implement regular audits, allocate resources for ongoing checks, and leverage technology-driven solutions such as computer-assisted coding (CAC) or HCC-driven software. Maintaining a robust compliance framework involves updating policies and procedures, conducting regular training, and staying vigilant to regulatory changes. This ensures efficient risk adjustment processes aligned with regulatory compliance.
Invest in your organization’s financial health and coding accuracy – contact our experts today to transform the way you approach HCC changes.
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