The shift from Hierarchical Condition Category (HCC) Version 24 (V24) to Version 28 (V28) is well underway, and healthcare organizations must now navigate the complexities of managing dual HCC models. As of 2024, the Centers for Medicare & Medicaid Services (CMS) is calculating 67% of risk scores using the legacy V24 and 33% with V28. This phased transition will continue through 2026, when all risk scores will be calculated using V28.
With these changes, organizations need to focus on improving processes, ensuring accurate clinical documentation, and adapting to evolving reimbursement models. In our latest guide, Evolving HCC Models: Navigating the Transition from Version 24 to Version 28, June Bronnert, MHI, RHIA, CCS, CCS-P, VP of Global Clinical Services at IMO Health, provides a comprehensive review of the key updates, the importance of documentation specificity, and strategies to manage the challenges posed by dual HCC models.
For a preview of the guide's insights, keep reading.
Features of HCC V28 and their impact
Updates to payment HCCs
V28 contains 115 payment HCCs. While this is an increase from 86 payment HCCs, there was a decrease of approximately 2,000 actual ICD-10-CM codes between V28 and V24. This supports HCCs that are clinically specific and provide granularity to support future resource utilization predictions.
In general, code changes were made to include ICD codes representing the more severe manifestation of diseases, while the codes representing less severe disease states were removed from payment HCCs. For example, in V24, codes I47.19 Other supraventricular tachycardia and I4729 Other ventricular tachycardia are in HCC 96 Specified Heart Arrhythmias. In contrast, HCC 238 Specified Heart Arrhythmia in V28 has just one of these two codes. The code I47.29 Other ventricular tachycardia continues in HCC 238 as Specified Heart Arrhythmia, which is typically considered a more severe form of heart arrhythmia.
Constraining coefficient factors
Constraining coefficient factors is another feature to be aware of in V28. Diabetic HCCs and congestive heart failure HCCs are constrained in V28. Constraining coefficient factors render each HCC to the same weight in the risk score. This is important to note when evaluating the impact of moving to 100% payment under V28. Under V24, each of these HCCs has distinct factors, with the more severe conditions having higher weighted scores reflecting increased healthcare utilization.
In Table 1, V28 HCCs related to congestive heart failure are more granular than V24 HCCs.
Even though V28 HCCs are separated into more detailed descriptions, the RAF weights are constrained to remain at .36.
