Medicare Advantage is on the brink of a significant restructuring as it transitions from V24 to V28 of the hierarchical condition categories (HCCs) risk adjustment model. In a recent Journal of AHIMA article, I partnered with Jeanie Heck, BBA, CCS, Education Consultant, to discuss the upcoming changes to risk adjustment coding and best practices recommendations to prepare.
These changes carry substantial implications for medical coding and clinical documentation integrity (CDI) professionals, as numerous deletions and additions to HCC categories will affect patients’ risk scores. These changes take effect in January of 2024 against a backdrop of rising Office of Inspector General (OIG) oversight of Medical Advantage organizations.
What Coding Experts Should Know …
As we transition to HCC V28, it is crucial to align your EHR with the new codes. HCC V28 coding introduces 115 HCC categories, compared to V24’s 86. Nearly all HCC categories will be renumbered, posing a challenge for coders accustomed to memorizing codes. The new version will also include over 900 deletions involving sequalae/subsequent codes.
Here are five other important aspects of Version 28 to keep in mind with further explanation of each in the full Journal of AHIMA article, available online to AHIMA members.
The risk score transition will occur in phases.
The process of “constraining” will be used for some diagnoses such as diabetes and congestive heart failure.
Disease interactions will remain the same.
Several notable conditions will be removed from the risk adjustment model in V28.
V28 introduces 268 new ICD-10-CM codes, increasing the number of payment HCCs to 115.
Our Best Practices to Navigate Changes Successfully
While this shift brings challenges, it also offers opportunities for healthcare organizations to improve documentation and coding practices, ultimately benefiting providers and patients. Here are five best practices for coding and CDI teams to prepare for January 2024:
Document all conditions that require or affect patient treatment, management, or medical decision-making.
Prioritize clinical specificity to capture the complexity of your patient.
Identify top HCCs in your patient population to understand the impact.
Map out each change that could alter your administrative workflow and how to reroute your operations.
Reprioritize which conditions to assess.
By implementing these best practices, coding and CDI teams can successfully navigate this transition and thrive under this new coding adjustment.
About the unparalleled expertise of Kim and Jeanie …
Kim Felix, RHIA, CCS
Director of Education
Kim Felix, RHIA, CCS has over 30 years of HIM coding experience including coder, auditor, manager, and educator. Education experience includes adjunct faculty at Temple University, Anne Arundel Community College, Gwynedd-Mercy College, Pierce College, Thomas Jefferson University and Study Mentor at Western Governors University. Presented at various nationwide conferences. Project manager for CMS HHS-RADV (Risk Adjustment Data Validation Audit) from 2016 to present. Developed ICD-10 training program, provides continual education sessions for clients and internal staff, developed CCS Preparatory Workshop and has published various articles in HFMA’s Revenue Cycle Strategist. Most recently received PHIMA’s 2023 Distinguished Member Award.
Jeanie Heck, CCS, CPC, CRC, ICD-10-CM Approved Instructor
Education Consultant
Jeanie Heck, CCS, CPC, CRC, ICD-10-CM Approved Instructor has over 30 years of experience as an expert physician and coder educator for CPT, ICD-10-CM and an accomplished Evaluation and Management auditor. She has been the lead senior auditor for the CMS HHS-RADV (Risk Adjustment Data Validation) audit for the past 7 years. She works with documentation improvement for coding integrity and HCC coding. Jeanie provides education regarding coding, auditing, and billing to physicians and their staff.
She is currently an adjunct faculty member at Camden County College and Santa Barbara City College teaching various coding courses. Her management positions include Director of Education, Coding and Billing Director, Practice Manager, and Business Manager. Ms. Heck’s most recent speaking engagements include topics such as Missed Opportunities in Coding and Billing, HCC Overview, and What you Need to Know about Risk Adjustment. She recently co-authored an article for the Revenue Cycle Strategist magazine entitled “Are you Ready for MACRA and MIPS? The New Healthcare Payment Reform”