With the Centers for Medicare & Medicaid Services (CMS) deciding to move from Hierarchical Condition Category (HCC) Version 24 (V24) to Version 28 (V28), many providers are preparing for how they will manage the three-year transition.
In IMO’s on-demand webinar CMS-HCC Version 28: Get informed and be prepared for change, our experts cover how risk adjustment factors (RAF) scores will be impacted by V28; the updates being made to ICD-10-CM and HCC mappings; and management strategies for the new blended payment model. We’ve compiled the most pressing questions from that webinar for you below.
If you’d rather dive into the full webinar, click here.
Question: Why is CMS updating to V28?
Answer: CMS is updating to V28 to improve the accuracy and specificity of the HCC model based upon ICD-10-CM. Transitioning to ICD-10-CM coding enhances data capture and cost prediction. It aligns with industry standards and provides a robust foundation for risk adjustment, ensuring accurate payment calculations.
Q: Has the industry been reporting ICD-10-CM codes long enough for the system to be updated or recalibrated?
A: Yes, CMS ran data analyses on ICD-10-CM codes reported by the industry for several years, allowing for the recalibration and analysis of the HCC model. It was decided that the ICD-10-CM coded claims data was sufficiently stable to predict future case expenditures. This led CMS to clinically reclassify the model from the ICD-9-CM based foundation to an ICD-10-CM based foundation for calendar year 2024.
Q: When will CMS-HCC V28 information be available in IMO releases?
A: HCC V28 information is targeted to be included in IMO’s September release, including terminology and problem list tools.
Q: How will CMS phase in the updated version of the model over the next three years?
A: CMS will implement a phased approach for the model transition. In Calendar Year (CY) 2024, 67% of risk scores will still be calculated using the current V24 model, while 33% will be calculated using the updated V28 model. Moving to CY 2025, CMS expects the distribution to shift, with 33% of risk scores being calculated using the V24 model and 67% using the V28 model. By CY 2026, CMS plans to calculate 100% of risk scores using the V28 model. This gradual transition ensures a smooth adoption of the updated model.
Q: How important will specificity remain for V28?
A: While HCC models evolve, one thing that remains constant is the importance of documenting conditions to the fullest clinical specificity. The specificity captures the complexity of a patient population and provides CMS with coded data for future analysis in model recommendations.
Q: Are there additional prompts for providers to support MEAT (monitoring, evaluation, assessment, and treatment) documentation guidelines?
A: The EHR-specific format can provide additional prompts to support MEAT documentation, and IMO can assist in organizing the data needed for documentation completion. It is important that providers capture their monitoring, evaluation, assessment, and treatment(s) of each patient’s disease state within their documentation. While EHR-specific formats and prompts are unique to each system, IMO can assist in providing robust clinical terminology to support detailed documentation.
Q: Is the social determinants of health (SDOH) terminology being incorporated into payment programs?
A: CMS is seeking information on SDOH to incorporate it into payment programs, acknowledging that a patient’s social situation can influence their overall health and risk.
Q: Is risk adjustment coding required for both V24 and V28 simultaneously?
A: Yes, risk adjustment coding needs to account for both versions since the impact of HCCs can differ between the two versions.
Q: Is CMS’ list of codes for the HCC changes available for review?
A: Yes, CMS’ proposed list of codes for the HCC changes can be found on their website under risk adjustment and other model documentation.
Q: Can IMO provide analytics on HCC capture and opportunities?
A: IMO can provide data analysis to help organizations understand their current HCC capture and identify opportunities for improvement. Message sales@imohealth.com to learn more.
Q: Is the transition from V24 to V28 finalized or still proposed?
A: The transition was proposed in January and finalized in April, and it is set to be implemented for the calendar year-end statement in 2024.
Q: Does IMO’s functionality extend beyond HCCs to other aspects of problem list management?
A: Yes, IMO’s functionality covers various elements of problem list management, including duplicate and lapsed problems.
