‘Significant Ramifications’: Medical Group Opposes HCC Coding Changes

By Amanda Norris for Health Leaders

CMS recently released proposed changes to the CMS-HCC Risk Adjustment Model for payment year 2024 in February, with a public comment period that ending surprisingly quick. These changes will directly affect Medicare Advantage organizations as the model informs payments to Medicare Advantage plans.

“The proposed changes (Model V28) would make significant changes to the existing V24. V24 was structured using the ICD-9-CM codes and, although translated to ICD-10-CM, did not provide the granularity we are now able to with code assignment,” Laurie Prescott, interim director for ACDIS and director of CDI education for HCPro, said in a recent issue of CDI Strategies. 

This change means that more specificity in code assignment will be required in a number of condition categories, upping the administrative burden on certain revenue cycle staff.

The proposal increases the number of payment-HCCs by 29, with a total of 115 payment HCCs.

“These 115 HCCs have been renumbered, and new names have been applied to many groupings. Within the methodology, 268 new codes have been identified, but in total V28 demonstrates a reduction of 2,027 diagnoses codes that provide risk adjustment within the present version,” Prescott wrote.

Major medical groups are now responding and taking aim at the short comment period, which was scheduled to end the first week in March.

The American Medical Group Association (AMGA) has asked CMS not to finalize these code changes.

According to AMGA, the proposed changes to the risk adjustment model would adversely impact healthcare providers participating in value-based care contracts.

In addition, AMGA disagrees that removing codes from the HCC model addresses discretionary coding variation, but instead would remove distinct clinical differences from the model.

“CMS should not move forward with its proposed change until stakeholders understand what the impacts of these changes will mean to the Medicare Advantage plan design and care delivery, particularly to patients with chronic conditions such as diabetes and congestive heart failure,” the AMGA said in a press release.

“Modifying the HCC model is not a simple technical update or revision,” said AMGA President and CEO Jerry Penso. “It’s likely to have significant ramifications, affecting both plans and providers. CMS should recognize that stakeholders can’t provide substantive, constructive feedback in such a short timeframe.”

If CMS’ proposals are finalized, Medicare Advantage plans must submit bids based on the new model by June 5.