How CMS-HCC Version 28 will influence risk adjustment factor (RAF) scores

For the purpose of estimating patients’ future healthcare expenses, the Centers for Medicare & Medicaid Services (CMS) unveiled the Risk Adjustment Factor (RAF) model in 2004. Value-based care relies heavily on RAF scores since they forecast the use of healthcare resources while accounting for patient expenses and quality. Healthcare organizations and providers must be ready for significant changes in how they code and capture patient risk by implementing the v28 HCC model. 

Medicare Advantage, the Medicare Shared Savings Program (MSSP), and REACH are just a few of the CMS initiatives the v28 HCC model will impact. This year’s RAF scores are factored into the blended transition model. Healthcare organizations that fail to learn the requirements of v28 and develop a strategy to act now will lose valuable dollars.

Understanding RAF Scores and Risk Adjustment

The Medicare Advantage payment system relies heavily on RAF scores. These scores represent the anticipated expenses and healthcare utilization related to an MA enrollee’s health state. When the RAF score is more excellent, the patient group is sicker, and the MA plan receives more payment to cover their care.

Using ICD-10 codes to capture diagnoses accurately is essential for risk adjustment vendors. Following this, these codes are translated to HCC categories, which give each condition a particular weight determined by its severity and resource usage. The weighted sum of all an enrollee’s HCC scores determines their RAF score.

How RAF scores are calculated

The RAF score is based on the beneficiary’s demographics and disease risk scores. The demographic score considers the following factors: age, sex, place of living (community, skilled nursing facility, or another institution), and impairment status. The disease risk score is based on the reported diagnoses from patient encounters and the associated Hierarchical Condition Category (HCC) codes.

Generally, those with higher RAF scores are considered sicker, whereas those with lower RAF scores are considered healthier. A low RAF score, however, can also indicate erroneous coding due to a care gap or a lack of information in the patient record.

Fundamental Changes Introduced in CMS-HCC V28

The HCC coding method is significantly altered by V28, which also affects how diagnoses are assigned to HCCs and, eventually, RAF scores. Below is a summary of the most significant modifications:

• Elimination of Codes: V28 removes more than 2,200 ICD-10 codes that were formerly associated with HCCs. This implies that some diagnoses will no longer be considered when determining an enrollee’s RAF score.
• Constraining Coefficients: V28 presents the idea of “constraining” for a few HCC groups. In essence, this gives related circumstances the same coefficient value. For instance, it is possible that V24 gave diabetes with severe acute consequences, diabetes with chronic difficulties, and diabetes with no issues with distinct weights. V28 may limit these groups by giving each of the three the same coefficient, which could affect the RAF scores of patients with these illnesses.
• New Codes: V28 adds new ICD-10 codes that correspond to the current HCCs and removes other codes. This may make it possible to record previously uncoded diagnoses and have a favorable effect on some RAF scores.
• Code-to-HCC Mapping Modified: V28 updates the mapping between some ICD-10 codes and HCC categories. As a result, specific diagnoses may be linked to distinct HCCs with disparate coefficient values, which may affect RAF scores based on particular modifications.

Impact on RAF Scores

The detailed combination of diagnoses among the beneficiaries of an MA plan determines the complex cumulative impact of these V28 modifications on RAF scores. Below is a summary of possible situations:

• Reduction in RAF Ratings: Many beneficiaries, especially those with previously coded diseases that are no longer considered under V28, are expected to see a fall in their RAF scores due to eliminating codes and restricting coefficients for specific conditions.
• Minimal Effect: The introduction of new codes or adjustments to the code-to-HCC mapping may, for some beneficiaries, offset the removal of existing codes, having no effect on RAF scores.
• Possible Rise in RAF Scores: Introducing new codes may enable the identification of previously uncoded illnesses, which could increase RAF scores for a subset of beneficiaries. However, because there are more code reductions, the overall impact will probably be smaller. 

Preparing for the Transition to V28

MA businesses must proactively plan for any changes in RAF scores in light of the staggered adoption of V28. MA businesses must proactively plan for any changes in RAF scores in light of the staggered adoption of V28. Here some important tactics are mentioned below that need to be thought about:

• Examine Benefit Information: Examine your enrolled beneficiaries’ current diagnoses to determine how V28 might affect their RAF scores. Potential code holes and opportunities can be found with the aid of tools like risk adjustment software.
• Educate Providers: Educate medical professionals on the changes brought about by V28 and the significance of precise and comprehensive diagnosis coding to guarantee that all pertinent conditions are recorded and suitably reflected in RAF scores.
• Refine Coding Procedures: Examine and revise procedures to account for the modifications made in V28. Use industry groups and CMS resources to guarantee precise code application and selection.
• Put Money into Technological Solutions: Use risk adjustment solutions tools to pinpoint missed diagnoses, assess the effects of V28 on RAF scores, and enhance coding procedures.
• Track Performance: During the V28 phase-in, consistently track RAF scores and look for patterns. This will allow you to modify coding procedures and spot opportunities to optimize reimbursement.

Strategies to Conquer the v28 Transition

Getting ready to switch to the v28 HCC model calls for a calculated strategy. It will be crucial to have an implementation strategy in place or on the verge of implementation as soon as feasible.

• Understanding Crosswalks: Learn in-depth information about mapping common conditions between v24 and v28.
• Patient Situations: To help with education and demonstrate the impact, provide instances of how the new model will change patients’ RAF scores over the next three years.
• Sorting by Providers and Patients: Arrange patients and providers in a corresponding order to determine potential revenue leakage risks and possibilities.
• Data Capture: Stress the significance of quickly obtaining V28 codes to prevent reimbursement problems in the upcoming year.
• Use Data Reports: Use data reports to demonstrate the effects on overall condition counts, RAF recapture percentages, and enterprise-level financial consequences.
• Evaluate Your Point-of-Care Options: Analyze how point-of-care remedies affect the rates of RAF recapture.

Wrapping Up

MA enterprises must be proactive in their approach to the adoption of CMS-HCC V28. Healthcare administrators and providers can successfully negotiate this shift by being aware of the important changes. They can also shift by assessing potential effects on RAF scores and implementing effective measures. In the changing healthcare environment, precise risk adjustment and optimal compensation depend on constant observation, teamwork, and a dedication to high-quality care.