Upcoming Changes to 2024 CMS-HCC Risk Adjustment Model Include Reliable Predictors of Future Costs

Upcoming Changes to 2024 CMS-HCC Risk Adjustment Model Include Reliable Predictors of Future Costs

HCCs and their effects on coding have been an increasingly hot topic in the industry over the past several years. Hierarchical Condition Categories (HCCs) were initially developed for risk adjustment in Medicare Advantage, but their use now expands to other payers. HCCs require more comprehensive coding, capturing specific diagnoses for accurate risk adjustment. In the 2024 CMS-HCC risk adjustment model, CMS has made changes by including reliable predictors of future costs and excluding unreliable ones (CMS, 2023).

In summary, the CY2024 CMS-HCC model classifies the ~74,000 ICD-10-CM diagnoses codes into 266 CMS-HCCs, 115 of which are in the 2024 payment model. This increase in condition categories from the 2020 CMS-HCC model (204 MCS-HCCs and 86 in payment) is due to the greater level of detail within ICD-10-CM diagnosis codes. In aggregate, the 2024 model contains approximately 20% fewer ICD-10-CM codes than the 2020 model, resulting from the removal of diagnoses per CMS’ risk adjustment principles.

Important Updates to the 2024 CMS-HCC Risk Adjustment Model

Below are some important updates to different categories within the risk adjustment model for the 2024 CMS-HCC model that will affect coders:

Vascular Disease

  • Three new HCCs (263, 264, and 267) were created by reconfiguring HCCs 107-108 in the 2024 CMS-HCC model.
  • The updated model focuses on more severe cases of atherosclerosis of arteries of extremities, while less severe manifestations are mapped to lower-level HCCs.

Metabolic Diseases

  • The Metabolic disease group in the 2024 CMS-HCC model expanded to four payment HCCs from three in the 2020 model.
  • High-cost lysosomal storage disorders were split into a new HCC (49).
  • Metabolic and endocrine disorders were separated into HCCs 50 and 51 based on cost and clinical considerations.
  • Other conditions with lower cost implications or indicating lab test results were mapped to non-payment HCCs.

Heart Diseases

  • The Heart disease group in the 2024 CMS-HCC model expanded to ten payment HCCs from five in the 2020 model.
  • HCC 85 Congestive Heart Failure was split into five payment heart failure HCCs (222-226) based on clinical severity and cost differences.
  • HCC 221 (Heart Transplant Status/Complications) was added to the hierarchy, and HCC 227 (Cardiomyopathy/Myocarditis) was split out as a separate HCC.
2024 cms-hcc risk adjustment model

Blood Disease

  • The Blood disease group in the 2024 CMS-HCC model expanded to seven payment HCCs from three in the 2020 model.
  • Coagulation defects, hemorrhagic conditions, and purpura were mapped to payment HCC 112 or non-payment HCC based on clinical severity and specificity.
  • Immune conditions were split into HCCs 114 and 115, with costlier and clinically severe conditions in HCC 114 and other specified disorders in HCC 115.

Amputation

  • The Amputation disease group in the 2020 CMS-HCC model was reconfigured in the 2024 CMS-HCC model to cover initial complications or ongoing costs of lower limb amputation.
  • Acquired absence codes for toe and finger were mapped to non-payment HCC to classify them accurately based on disease burden and cost prediction.

Neurological Diseases

  • The Neurological disease group in the 2024 CMS-HCC model expanded to twelve payment HCCs from eight in the 2020 model.
  • HCC 75 was reconfigured into HCCs 193-196 based on underpredicted and chronic codes.
  • Acute Guillain-Barre Syndrome became a non-payment HCC. Myasthenia gravis codes were reconfigured into two payment HCCs based on clinical severity and cost differences.

Diabetes

  • The Diabetes disease group in the 2024 CMS-HCC model has four payment HCCs. HCC 35 is at the top of the hierarchy.
  • Diagnosis codes for diabetes with unspecified complications and complications related to glycemic control were moved to the lowest payment HCC (HCC 38).
  • Severe acute complications related to glycemic control remain in the highest payment HCC (HCC 36). Some drug-induced diabetes codes were mapped to non-payment HCCs.

Kidney Disease

  • The Kidney disease group in the 2024 CMS-HCC model has four payment HCCs. HCC 138 is replaced with more granular HCCs (328 and 329) based on new ICD-10 codes.
  • HCCs related to dialysis status and acute kidney failure were removed from the payment model. New HCCs (324 and 325) were added based on chronic kidney disease (CKD) stages.

Frequent Asked Questions about the latest HCC Coding Updates (2024)

2024 CMS-HCC Risk Adjustment Model
What are the key updates in the 2024 CMS-HCC model for vascular diseases?

The 2024 CMS-HCC model introduces three new HCCs (263, 264, and 267) by reconfiguring HCCs 107-108. The updated model focuses on more severe cases of atherosclerosis of arteries of extremities, while less severe manifestations are mapped to lower-level HCCs.

How has the metabolic disease group changed in the 2024 CMS-HCC model?

In the 2024 CMS-HCC model, the metabolic disease group expanded to four payment HCCs from three in the 2020 model. High-cost lysosomal storage disorders were split into a new HCC (49), and metabolic and endocrine disorders were separated into HCCs 50 and 51 based on cost and clinical considerations. Other conditions with lower cost implications or indicating lab test results were mapped to non-payment HCCs.

What updates have been made to the heart disease group in the 2024 CMS-HCC model?

The heart disease group in the 2024 CMS-HCC model expanded to ten payment HCCs from five in the 2020 model. HCC 85 Congestive Heart Failure was split into five payment heart failure HCCs (222-226) based on clinical severity and cost differences. HCC 221 (Heart Transplant Status/Complications) was added to the hierarchy, and HCC 227 (Cardiomyopathy/Myocarditis) was split out as a separate HCC.

These FAQs cover important updates in the 2024 CMS-HCC model. They inform coders about the changes related to HCCs and coding for accurate risk adjustment.

Need HCC Coding Support?

Our specially trained YES coding consultants can navigate the updates to the 2024 CMS-HCC risk adjustment model with ease. Schedule a free consultation or email us today to learn more about our HCC coding services.

Additional HCC Resources

Vanessa Youmans

Vanessa Youmans, MA, CCS, CPC – Chief Operating Officer (COO)
2024 cms-hcc risk adjustment model

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