CurrentFlorida BluePolicy N/A

CMS-HCC Risk Adjustment Model Version 28 (V28) Advance Notice

Summarizes CMS's 2024 update to the Medicare Advantage CMS-HCC risk adjustment model (V28), changes to HCC mappings, model recalibration and phased-in blending with the prior model; affects Medicare Advantage risk scoring and payers/providers coding and payment expectations.

Policy Summary

PayerFlorida Blue

PolicyCMS-HCC Risk Adjustment Model Version 28 (V28) Advance Notice

Policy CodePolicy N/A

Change TypeModel update with recalibration, reclassification, and phased blending

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionPrepare for changes in risk adjustment scoring due to reclassification and remapping of diagnosis codes; monitor which ICD-10-CM codes no longer map to payment HCCs and which new codes are added.

SourceLink

POLICY UPDATE CHANGES

The CMS-HCC Model (V28) increases payment HCCs from 86 to 115 and maps 7,770 ICD-10-CM codes to payment HCCs.

Model recalibration updated data years used for calibration from 2014-2015 to 2018-2019 and baseline denominator year from 2017 to 2020.

Risk scores will be phased in as a blend of the current model (V24) and new model (V28) over 2024-2026 with specified percentages each year.

115payment HCCs in CMS-HCC Model V28

7,770ICD-10-CM codes mapped to payment HCCs in V28

2,236ICD-10-CM codes no longer mapped to payment HCCs

Policy Summary

PayerFlorida Blue

PolicyCMS-HCC Risk Adjustment Model Version 28 (V28) Advance Notice

Policy CodePolicy N/A

Change TypeModel update with recalibration, reclassification, and phased blending

Effective DateJan 1, 2024

Next Review DateN/A

SourceLink

On This Page

HCC Inclusion, Exclusion, and Implementation Rules (V28)

V28 HCC inclusion/exclusion and implementation

Criteria for inclusion or exclusion of HCCs in the V28 model and the resulting mapping and implementation changes:

HCCs included if they meaningfully predict costs based on recalibrated data and specified diagnostic coding criteria.

Exclusion criteria (one or more):

Condition did not accurately predict costs.
Condition had small coefficients (limited impact on predicted cost).
Condition was uncommon.
Condition lacked specified diagnostic coding criteria (Principle 10 consideration).

Operational changes from reclassification: the model increases payment HCCs from 86 to 115, maps 7,770 ICD-10-CM codes to payment HCCs, and 2,236 ICD-10-CM codes no longer map to a payment HCC.

Implementation timing: risk scores will be phased in as a blend of the current model (V24) and new model (V28) over 2024–2026 (2024 = 67% V24 / 33% V28; 2025 = 33% V24 / 67% V28; 2026 = 0% V24 / 100% V28).

ICD-10-CM to HCC Mapping and Example Code Changes

Examples of codes removed in V28ICD-10Not Covered

D69.2	Other nonthrombocytopenic purpura (no longer maps to payment HCC in V28)
D84.81	Immunodeficiency due to conditions classified elsewhere (no longer maps to payment HCC in V28)
E44.0	Moderate protein-calorie malnutrition (no longer maps to payment HCC in V28)
F33.0	Major depressive disorder, recurrent, mild (no longer maps to payment HCC in V28)
I20.8	Other forms of angina pectoris (no longer maps to payment HCC in V28)
I70.0	Atherosclerosis of aorta (no longer maps to payment HCC in V28)
I70.201	Unspecified atherosclerosis of native arteries of extremities, right leg (no longer maps to payment HCC in V28)

Examples of codes added in V28ICD-10Covered

F50.00	Anorexia nervosa, unspecified (added to V28, maps to HCC 153)
J45.50	Severe persistent asthma, uncomplicated (added to V28, maps to HCC 279)
J91.0	Malignant pleural effusion (added to V28, maps to HCC 17)
K70.10	Alcoholic hepatitis without ascites (added to V28, maps to HCC 65)
K71.3	Toxic liver disease with chronic persistent hepatitis (added to V28, maps to HCC 65)

ICD-10-CM codes mapped to payment HCCs (V28)

Total ICD-10-CM codes mapped to payment HCCs (V28)7,770

ICD-10-CM codes no longer mapped to payment HCCs2,236

Net codes added vs removed209 added; 2,236 removed (net decrease)

Payment HCC count in V28115 payment HCCs (increased from 86 in V24)

Provider Coding, Documentation, and Risk-Score Monitoring

Documentation Required

Monitor and update coding and risk-score workflows for CMS‑HCC V28

Prepare for changes in risk adjustment scoring due to reclassification and remapping of diagnosis codes; monitor which ICD-10-CM codes no longer map to payment HCCs and which new codes are added, and track the phased blending of V24 and V28 risk scores during 2024–2026.

V28 maps 7,770 ICD-10-CM codes to 115 payment HCCs while 2,236 codes no longer map to payment HCCs (V28).
Risk scores will be phased in as a blend: 2024 = 67% V24 / 33% V28; 2025 = 33% V24 / 67% V28; 2026 = 0% V24 / 100% V28.

Key Terms and Principles

CMS-HCC risk adjustment model

DefinitionA statistical model used by CMS to estimate future health care costs for Medicare Advantage beneficiaries by mapping diagnosis codes to hierarchical condition categories (HCCs) and assigning risk scores.

PurposeTo improve or maintain predictive accuracy of estimated future costs across beneficiary subgroups by mapping diagnoses to HCCs.

Implementation noteV28 will be phased in as a blend with the prior model (V24) over 2024–2026 (2024: 67% V24 / 33% V28; 2025: 33% / 67%; 2026: 0% / 100%).

Principle 10 (exclusion of discretionary diagnostic categories)

Principle 10 — core ruleExclude discretionary diagnostic categories from payment models when diagnoses are subject to intentional or unintentional discretionary coding variation or inappropriate coding.