The Centers for Medicare & Medicaid Services (CMS) introduced the Risk Adjustment Factor (RAF) model in 2004, which was designed to estimate future healthcare costs for patients. RAF scores are a critical component of value-based care, as they help predict healthcare resource utilization while adjusting for quality and costs for patients. With the introduction of the v28 HCC model, healthcare providers and organizations must be prepared for significant changes in the way they code and capture patient risk.
The v28 HCC model will impact multiple CMS programs, including Medicare Advantage, the Medicare Shared Savings Program (MSSP), and REACH. With this year’s RAF scores being factored into the blended transition model, healthcare organizations that fail to learn the requirements of v28 and develop a strategy to act now will lose out on valuable dollars.
Read on as we delve into the key aspects of the v28 HCC model, work to understand the model’s impact on RAF scores, and share strategies to help you conquer the transition.
Overview of the v28 HCC Model
The HCC (Hierarchical Condition Category) coding system paints a comprehensive picture of a patient’s level of complexity, allowing healthcare providers to assess their healthcare needs accurately. RAF scores derived from these codes play a vital role in predicting the acuity and cost of a patient, serving as a financial benchmark for payment allocation.
CMS makes small adjustments to the HCC coding system each year, which can include removing or adding certain categories or ICD-10 codes, modifying calculations, or alterations to HCC categories themselves. However, v28 marks the most significant revision to the model since its creation and brings important changes that will impact healthcare organizations.
Key Changes in the v28 HCC Model
- Code Changes: Over 2,200 diagnosis codes have been removed, while more than 200 new codes were added
- Remapping of ICD-10s: The remapping of ICD-10 codes between HCC categories will affect how certain conditions are evaluated
- Coefficient Values: Changes in coefficient values will impact the weight given to different diagnoses in calculating the RAF score
- HCC Category Changes: Reorganizing HCC categories further complicates coding and risk assessment, forcing healthcare professionals to relearn the available HCC categories
- Specificity Changes: With the introduction of new categories and codes, being highly specific and intentional will be instrumental in accurate disease coding
Transitioning from HCC v24 to HCC v28
The transition from HCC model v24 to v28 will not happen overnight. A blended version of the model will be in place for the next three years, from 2024 to 2026. Since 2023 scores impact the 2024 performance year, making necessary changes now will ensure you do not fall behind during this transitional period. Healthcare organizations must focus on streamlining education and awareness among their provider community to ensure proper coding and data capture.
Several metrics and challenges must be closely monitored during this transition, including:
- Ensuring that annual wellness visits and office visits are completed promptly
- Measuring how effectively diagnosis codes are being recaptured
- Paying attention to newly introduced codes, which are crucial during the blended model phase
- Carefully projecting revenue for the upcoming payment year to avoid financial discrepancies
- Working with your EMR vendor to ensure captured codes map correctly to v28
One of the significant changes in the v28 HCC model is the reduction in RAF scores for commonly coded conditions. The best example of this is observed in the values of various diabetes codes, including diabetes with no complications, diabetes with chronic complications, and diabetes with severe acute complications. Rather than each variant having a different value, in v28, these codes now have the same value and are coded the same.
Strategies to Conquer the v28 Transition
Preparing for the transition to the v28 HCC model requires a strategic approach. Having a strategy that is implemented or on the path of implementation as soon as possible will be critical.
- Crosswalk Understanding: Gain a comprehensive understanding of how common conditions map between v24 and v28
- Patient Scenarios: Provide examples of how the new model will affect patients’ RAF scores for the next three years to facilitate education and show the impact
- Sorting by Providers & Patients: Identify opportunities and revenue leakage risks by sorting patients and providers accordingly
- Data Capture: Emphasize the importance of capturing v28 codes immediately to avoid reimbursement issues in the coming year
- Use Data Reports: Utilize data reports to illustrate the impact on total condition counts, RAF recapture percentages, and financial implications at an enterprise level
- Assess Point-of-Care Solutions: Measure the impact of point-of-care solutions on RAF recapture rates
The introduction of CMS’s v28 HCC model is a significant development in the healthcare industry, impacting how risk adjustment and value-based care are managed. Healthcare organizations must invest in education, coding accuracy, and data capture to ensure a smooth transition and accurate RAF scores. Adapting to these changes will be crucial for maintaining financial stability while providing quality care to patients. By understanding and effectively managing the v28 HCC model, healthcare providers can navigate the evolving landscape of value-based care successfully.
Today, Lightbeam has the functionality to help healthcare organizations navigate the change from v24 to v28 by capturing conditions accurately under the blended model. We strive to truly partner with our client organizations to ensure they have the tools they need to pivot through unexpected challenges and turn them into opportunities.
President of Government & Value-Based Programs