The healthcare industry is ever-changing, and staying abreast of regulatory changes is paramount for healthcare professionals and hospitals. In 2024, the Centers for Medicare & Medicaid Services (CMS) introduced significant updates to the Hierarchical Condition Categories (HCCs) Risk Adjustment Model. Understanding these changes is crucial for accurate risk assessment, HCC coding, and reimbursement in the healthcare industry.
In this comprehensive guide, we delve into the intricacies of the 2024 CMS-HCC Risk Adjustment Model, exploring the modifications made to various disease categories and their implications. Whether you're a coder or healthcare provider, this guide aims to equip you with the knowledge needed to navigate the changing scenario of risk adjustment in healthcare. Let’s have a look at the updates:
Updates in the 2024 CMS-HCC Risk Adjustment Model
Vascular Diseases
In the 2024 CMS-HCC risk adjustment model, significant changes have been made to the Vascular Disease category. Three new HCCs (263, 264, and 267) were introduced by reconfiguring HCCs 107-108. The focus has shifted to more severe cases of atherosclerosis of arteries of extremities, with less severe manifestations now mapped to lower-level HCCs. This adjustment aims to represent vascular conditions better, allowing for accurate risk assessment and appropriate payment adjustments.
Metabolic Diseases
The Metabolic Disease group in the 2024 CMS-HCC model has expanded to four payment HCCs from three in the 2020 model. Notably, high-cost lysosomal storage disorders now have a dedicated HCC (49), and metabolic and endocrine disorders were separated into HCCs 50 and 51 based on cost and clinical considerations. This increased detail ensures a more accurate representation of metabolic conditions, allowing for improved risk adjustment and payment precision.
Heart Diseases
The Heart Disease group in the 2024 CMS-HCC model has undergone significant expansion, now comprising ten payment HCCs compared to five in the 2020 model. HCC 85, Congestive Heart Failure, has been split into five payment heart failure HCCs (222-226) based on clinical severity and cost differences. Additionally, HCC 221 (Heart Transplant Status/Complications) was added to the hierarchy, and HCC 227 (Cardiomyopathy/Myocarditis) was separated as a distinct HCC. These changes provide a more detailed and accurate assessment of heart-related conditions for risk adjustment purposes.
Blood Diseases
The Blood Disease group in the 2024 CMS-HCC model has expanded to seven payment HCCs from three in the 2020 model. Coagulation defects, hemorrhagic conditions, and purpura are now mapped to payment HCC 112 or non-payment HCC based on clinical severity and specificity. Immune conditions were divided into HCCs 114 and 115, with costlier and clinically severe conditions in HCC 114 and other specified disorders in HCC 115. These adjustments aim to provide a more accurate representation of blood-related disorders for risk adjustment and payment accuracy.
Amputation Disease
The Amputation Disease group in the 2024 CMS-HCC model has been reconfigured to cover initial complications or ongoing costs of lower limb amputation. Acquired absence codes for toe and finger were mapped to non-payment HCCs to classify them accurately based on disease burden and cost prediction. These changes aim to capture better the complexities and costs associated with amputation cases for more precise risk adjustment.
Neurological Diseases
The 2024 CMS-HCC model now includes twelve payment HCCs for the Neurological Disease group, marking an expansion from the eight HCCs present 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, and 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 now has four payment HCCs, including the addition of HCC 35 at the top of the hierarchy. Codes for diabetes with unspecified complications and complications related to glycemic control have been shifted to the lowest payment HCC (HCC 38). Severe acute complications associated with glycemic control are still placed in the highest payment HCC (HCC 36), and certain drug-induced diabetes codes have been mapped to non-payment HCCs. These adjustments provide a more detailed assessment of diabetes-related conditions for accurate risk adjustment and payment precision.
Kidney Diseases
The Kidney Disease group in the 2024 CMS-HCC model has four payment HCCs, replacing HCC 138 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, and new HCCs (324 and 325) were added based on chronic kidney disease (CKD) stages. These adjustments aim to provide a more accurate representation of kidney-related conditions for risk adjustment and payment precision, aligning with the changing regulations of ICD-10 codes.
Conclusion
The 2024 CMS-HCC Risk Adjustment Model shifts how healthcare professionals approach risk assessment and coding. With approximately 74,000 ICD-10-CM diagnosis codes now classified into 266 CMS-HCCs, the model reflects a more detailed understanding of various medical conditions.
Healthcare professionals must adapt to these changes, ensuring that coding practices align with the updated model to capture the complexity of patient conditions accurately. By staying informed and implementing best practices, healthcare providers can navigate the intricate scenario of risk adjustment, contributing to improved patient care and fair reimbursement. As we move forward, collaboration with outsourcing medical billing companies such as 24/7 Medical Billing Services will be vital in maintaining compliance and optimizing healthcare delivery in the dynamic environment of the CMS-HCC Risk Adjustment Model.
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