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Impact of Proposed HCC Changes

Are you ready for some potentially big changes in the CMS-HCC model?  In February, CMS proposed many changes in the model–including for the first time actually using ICD-10 diagnosis codes to create the HCC groupings as opposed to using a cross-walk from ICD-9.  The model is expected to be finalized in April of this year and scheduled to take effect in January 2024.


Some of the proposed changes:

  1. Increase the number of payment HCCs from 86 to 115.
  2. Decrease the number of ICD-10 codes which map to an HCC from 9797 to 7770
  3. Remove from a payment HCC – 3 HCCs
    • HCC 47 – Protein-calorie malnutrition
    • HCC 230 – Angina Pectoris
    • HCC 265 -Atherosclerosis of Arteries of the Extremities, with Intermittent Claudication
  4. HCC constraints (i.e., hold the coefficients of the HCCs equal to each other such that each HCC carries the same weight):
    • Diabetes HCCs 36, 37, and 38
    • CHF HCCs 224, 225, and 226

These changes may lead to significant changes in risk scores when compared to the previous year.  Below are some examples of risk score changes looking at community, nondual, aged population.

Diagnosis  Risk Score 2023   Proposed Score 2024 
Diabetes with Chronic Complications 0.302 0.166
Morbid Obesity 0.25 0.186
Colorectal, Bladder and other cancers 0.307 0.363
Breast, Prostate and other cancers 0.15 0.186
Congestive heart failure 0.331 0.360
Cancer metastatic to other organs 2.659 4.209
Cancer metastatic to bone 2.659 2.341


The Need for Specificity

The need for specificity cannot be overly stressed.  There are now 7 members in the cancer hierarchy and as seen in the above example, the weight around metastatic disease is significantly impacted if there are metastasis to solid organs compared to other sites.  With CHF it’s also important to be specific since end stage CHF falls into a different HCC which is higher weighted than just severe CHF.

The important part is to pay particular attention to specificity of diagnosis and as always be certain that every diagnosis reported meets the MEAT (Monitor, Evaluate, Assess, Treat) requirements.  With the inclusion of additional members in a hierarchical family, specificity is extremely important. Another tip: be certain that there is clarity in the record regarding “active” disease versus “history of” disease.


Time to Prepare

Aside from these changes there is also a change in the payments for number of HCCs present.  An additional payment will only be provided for 5 or more as opposed to 4 or more presently.

At this point it is hard to know if these changes will have a positive or negative impact upon your risk scores but certainly there will be a change and it’s important to begin to prepare and educate around these changes.  The model is predicting a 3.12% decrease in risk scores overall.  As can be seen from some of the above examples, there are winners and losers in HCC categories.

Now is the time to begin preparing for these changes with education to providers and coding staff… and to be on the lookout for finalization of these proposals.


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