Medical practices are assessing the impact of the change in HCC model from V24 to V28, a phased in change that begins in 2024.

CMS pays Medicare Advantage (MA) plans using Hierarchical Condition Categories (HCCs) and the HCC model is used by many private payers and ACOs for risk adjustment. Briefly, Medicare pays MA plans more for patients with a higher disease burden, as measured by their risk score – (Risk scores also include demographics and geographic location). In recent years, based on OIG audits, CMS has come to believe there is upcoding being done by MA plans. And, naturally, they have implemented changes for 2024.

• Slides
• CMS V24 and V28 mappings_PY 2024 proposed

In the current year, MA plans are paid on the 2020 version, V24. CMS proposed changing to V28 (I know, skipped a few versions) starting January 2024, but compromised on phasing in V28 over three years. In 2024, 33% of the risk score will be based on V28, and the remainder on V24.  Why do we care? The change will very likely decrease overall risk scores.

• The number of HCC categories will increase from 86 to 115, and categories are renumbered.
• A change to a very commonly reported condition is diabetes, which has decreased values in V28. Some categories are eliminated entirely. V28 assigns a risk score to 2,264 fewer diagnosis codes.
• The current HCC categories were developed using ICD-9 codes. (We did switch to ICD-10 in 2015, if my memory is correct….) The new categories are built around the structure of ICD-10 codes and use the clinical concepts in that coding system.

Does this mean you will change your current diagnosis coding practices? No, of course not.  It means that the risk score that is calculated for an individual patient or a panel of patients will change, and could decrease, as V28 is phased in.

Need a refresher on risk adjustment? Watch our webinar or download the risk guide.  The risk guide uses V24 values—watch for our update.