Risk adjustment: A look at version 28 2024

For the past year, I’ve been immersed in the world of hierarchical condition category (HCC) coding. It's been a great opportunity to dig deeper into everything related to risk adjustment (RA) and is another skill I’ve added to my knowledge base. Just as I was getting used to the 2020 V24 risk adjustment model, the Centers for Medicare & Medicaid Services (CMS) made some much-needed updates and released V28 2024. Version 28 was finalized in April 2023 and will apply to 2023 dates of service.

Health care organizations will want to pay close attention to the 2024 risk adjustment updates. Before implementing the 2024 changes, the 2020 risk adjustment model used diagnosis codes from 2014 and costs from 2015. This means ICD-9-CM codes continued to be used, and many of these codes are no longer correctly mapped to an HCC code. Not only were outdated diagnosis codes used, but certain diseases may no longer have the same impact on patients, and emerging diseases must be configured into the cost of care. CMS has indicated V28 changes will be phased in over the next three years.

2024 updates

Several changes to the 2024 risk adjustment model (RA model) are worth noting. The disease categories and conditions most impacted by the changes include vascular, metabolic, heart, blood, amputation, neurological, diabetes, kidney, psychiatric and musculoskeletal. Below are highlights of the changes made in the new model:

Diabetes

• The 2020 RA model contained three payments for HCC. In 2024, the RA model will have four payments for HCC.  
• Diabetes codes with unspecified complications or complications related to blood sugar were moved to the lowest payment, and drug-induced diabetes codes were categorized as non-payment HCC.   
• HCC code 298 has been created for diabetic eye disease and other eye-related issues.

Psychiatric

• Diagnoses for mild, unspecified remission, subsequent encounter and sequela codes are now a non-payment HCC based on the diagnoses not being clinically relevant or a reliable indicator of future costs. 
• New codes added include F50.00-F50.02 for anorexia and F50.2 for bulimia nervosa. 
• Codes removed include major depressive disorders, mild, partial or complete remission, and recurrent major depressive disorder, unspecified. Also removed were subsequent and sequela suicide attempts and unspecified mood disorder.

Heart disease

• Version 28 contains 10 HCCs for heart conditions. 
• Angina codes, except for unstable type and supraventricular tachycardia, have been removed from being risk-adjusted.   
• Neonatal cardiac failure and initial encounters with artificial heart complications have been added for RA.

Musculoskeletal

• Version 28 now includes HCC 92 (bone/joint/muscle/severe soft tissue infections/necrosis), 93 (rheumatoid arthritis and other specified inflammatory rheumatic disorders) and 94 (systemic lupus erythematosus and other specified systemic connective tissue disorders). 
• New codes D86.86 (sarcoid arthropathy), D86.87 (sarcoid myositis), G72.41 (inclusion body myositis) and N94.3 (Fournier gangrene) were added. 
• Several diseases were moved from musculoskeletal HCCs, including drug-induced systemic lupus erythematosus, spinal enthesopathy, sacroiliitis not elsewhere classified and other specified inflammatory spondylopathies.

In total, more than 2,000 codes were removed from the current model because they no longer mapped to an HCC.

Understanding the recent changes and communicating effectively with your coders and physicians is critical to successfully documenting, coding and paying for risk adjustment. Now is an ideal time to review, and to educate coders, CDI teams and physicians on the recently enacted updates.  

Karla VonEschen is a coding analyst at Solventum.