Medicare Advantage (MA) plans and Accountable Care Organizations (ACOs) should be reevaluating their vendor strategy in light of coming changes. 

This is largely because of a new version of the Hierarchical Condition Category (CMS-HCC) risk adjustment model that CMS released in 2023. It includes changes that will enhance the value of partnering with an experienced vendor for in-depth retrospective and concurrent risk adjustment reviews. Leaders at these organizations will benefit from taking the time to review the information below and use it to fuel their strategy around risk adjustment coding and HCC medical coding

Coming Changes Affecting Risk Adjustment Coding
CMS-HCC version 28 brings with it changes that should move leaders at ACOs and MCOs to review their risk adjustment strategy [1]. 

The revisions include technical updates including updated data years for calibration and also an updated denominator year for calculating the average per capita expenditures predicted. This means that the revised risk adjustment model will involve changes including: 

  • HCC names and numbers 
  • Adding 29 new HCCs
  • HCC mapping
  • Coefficient HCC values
  • 2,294 diagnosis codes were removed that previously mapped to an HCC 
  • 268 diagnosis codes were added that previously did not map to an HCC 

Impact on Patients
ACOs will need to pay particular attention to how this new version impacts them since they could be put at a disadvantage, especially those that have a higher proportion of patients with conditions that are weighted lower under V28 than V24. ACO leaders should know that in extreme cases, V28 drops some conditions entirely.

Why MA Plans and ACOs Should use Experienced Vendors
The complexity of these changes will be too much for many MA plans and ACOs to handle effectively. This means that a vendor experienced in risk adjustment coding can be a valuable asset in navigating this change. Here are some of the ways an experienced vendor can help.

Maintaining effective management of risk adjustment programs
Your risk adjustment program should keep up with, and even get ahead of changes like these. You should be prioritizing comprehensive risk adjustment documentation to paint a holistic view of patient health, all to optimize care plan creation, improve outcomes, support cost reduction, and maximize reimbursement. 

This, though, requires staff and tactics that are continuously trained and updated to keep up with changes, meaning that the resources needed to achieve this internally can be extensive, as well as a drain on management. 

Supporting Coding Quality
Quality is a critical foundation of risk adjustment coding and HCC medical coding. HCC models are advanced risk-adjustment models and can be incredibly complex, requiring highly skilled coders who ensure complete documentation and assign appropriate diagnosis codes if conditions meet the TAMPER or MEAT criteria. 

Coding talent is in a shortage right now and experienced coders are retiring, meaning higher costs in acquisition and retention of this skill set. 

Keeping Costs Low Amid Change
Change can be expensive. Between training, candidate acquisition, and even planning time of your managers, your costs in adapting and maintaining your risk adjustment coding program can quickly begin to creep up. At the same time, simple missteps can mean lost revenue and complexity that could have been avoided. In many cases, the cost of a vendor can be lower than the total cost of trying to navigate change alone, especially when opportunity cost is factored in. 

Maintaining Healthy RAF Scores
CMS has already acknowledged that the changes to this rule could affect beneficiary risk scores even if a patient’s health status is unchanged. This means that your RAF scores could deteriorate in ways you haven’t encountered before, causing severe financial impact. For example, type 2 diabetes mellitus patients without complications will see a slightly higher coefficient in V28, resulting overall in a serious reduction in the score for patients with acute or chronic complications. 

Getting ahead of future impact to RAF scores through risk adjustment reviews
Retrospective and concurrent risk adjustment reviews are a reliable way to assess the level of risk associated with a patient’s health and determine a list of potential HCC diagnosis codes that should be considered during a future encounter. 

To support organizations like yours in their risk adjustment coding efforts, we offer comprehensive services including HCC medical coding and risk adjustment reviews (concurrent and retrospective) to help you improve clinical documentation and coding accuracy. To learn how you can leverage our experience as a risk adjustment coding vendor, we encourage you to contact us today with any questions.

[1] AAPC, “Get Ready for CMS-HCC V28,” 30 June 2023. Available:

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