The proposed CMS-HCC model for 2024 (V28) is on its way. What to expect?
For CY 2024, CMS proposes implementing a revised version of the CMS-HCC risk adjustment model. This proposed model has the same structure as the 2020 CMS-HCC risk adjustment model currently used for payment in that it has eight model segments as first implemented for payment for CY 2017 and condition count variables as first implemented for payment for CY 2020. It contains technical updates such as a clinical reclassification of the hierarchical condition categories (HCCs) using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes.
The proposed model includes the removal of several HCCs to reduce the impact on risk scores of MA coding variation from FFS because CMS noticed that some conditions are coded more frequently in MA relative to FFS.
CMS proposes to use this revised model in Part C payment for aged/disabled beneficiaries enrolled in MA plans beginning with the payment year 2024. The proposed model results in more appropriate relative weights for the HCCs in the model because they reflect more recent utilization, coding and expenditure patterns in FFS Medicare, as well as revised HCCs that are constructed to reflect clinical cost patterns associated with ICD-10 codes.
CMS identified several diagnoses and condition categories determined to be reclassified. The reclassification involved:
Moving some discretionary diagnosis codes from condition categories included in the CMS-HCC model to condition categories not included in the model.
Removing from the model several condition categories that do not accurately predict the projected cost of a beneficiary: HCC 47 Protein-Calorie Malnutrition / HCC 230 Angina Pectoris / HCC 265 Atherosclerosis of Arteries of the Extremities, with Intermittent Claudication
Constraining HCCs to be equal to each other to carry the same weight in the risk score: Constrained all Diabetes HCCs (HCC 36, 37, and 38) / Constrained Congestive Heart Failure HCCs (HCCs 224, 225, and 226).
The proposed 2024 CMS-HCC model has 115 payment HCCs, up from 86 in the current model. This increase in HCCs is due to newly-created HCCs added to the model and the splitting of several existing HCCs resulting from changes in the structure and clinical specificity of codes from ICD-9 to ICD-10, as well as changes in clinical concepts for some conditions. Beneficiary risk scores may change depending on each beneficiary’s combination of diagnoses.
Differences in the HCCs in the current (V24) CMS-HCC risk adjustment model and HCCs in the proposed V28 model are reported in the Table below.
​2020 model (V24) | ​Proposed model (V28) |
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HCCs with the same, or similar, label in V24 and V28 may have differences in the underlying ICD-10 codes that map to the HCC, meaning that the same, or similar, HCC label does not necessarily imply that the HCC is unchanged from V24 to V28. Similarly, V24 and V28 disease groups may not have the same underlying ICD code mappings. There are hierarchical relationships among some HCCs, such that a beneficiary may not be able to have all of the HCCs in a disease group in a given year.
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