The business side of being a clinician…it has to be talked about.
If you do this how you were trained in residency…you could go out of business. It has nothing to do with how skilled you are at seeing patients and everything to do with how to think about diagnosis.
Proper HCC diagnoses are key to our survival as clinics. They are important to the business side of healthcare. Anyone working in healthcare needs to understand this, and if you work in health tech or any clinical services that impact care… You must be aware and able to communicate this. You could be missing your value proposition if you don’t understand what is changing.
Before we get into it, I get it that this has nothing to do with proper clinical care… It’s the world that we live in.
First off, you may have heard of the changes that CMS has made to the model. With the change from Version 24 to Version 28, there is a likelihood of a reduction of the average HCC score of about 3.1% if you do not adjust. (For more information, see CMS website)
Your HCC/Risk adjustment factor (RAF) strategy should front of mind through this year and into the next.
Here’s a structured breakdown of the changes between CMS‑HCC Version 24 and Version 28—highlighting which conditions saw the most change.
Of course, I used AI to help collate and pull some sources. Enjoy!
🗂 Overview of Model Changes
HCC Count & ICD-10 Mapping
HCCs increased from 86 to 115.
ICD‑10-CM codes mapped to HCCs decreased from ~9,797 down to ~7,770 (a removal of ~2,294 codes and addition of ~268 new ones). (HiACode, Medicare & Medicaid Portal)
Reclassification & Renumbering
Many HCCs were renamed or renumbered to align with ICD‑10.
Diagnosis grouping built from ICD-10 data (2018–2019 data used in V28 vs ICD‑9 base in V24). (HiACode,Forvis Mazars)
RAF Coefficient “Constraining”
Related HCCs are often assigned identical risk coefficients.
Example: Diabetes with and without complications now share the same coefficient. (HiACode, Medicare & Medicaid Portal)
Phased Rollout
2024: 33% V28, 67% V24
2025: 67% V28, 33% V24
2026: 100% V28 (HiACode,kwadvancedconsulting.com)
Changes by Condition Group & Notable HCC Shifts
1. Diabetes
V24 had separate HCCs: uncomplicated (HCC 17), and complication subsets (HCC 18, 19).
V28 consolidates these into one (HCC 36–38), leveling the coefficient regardless of severity (HiACode, RAAPID INC, CodingIntel).
2. Mental & Behavioral Health
Major depressive disorder, anxiety removed from HCC mapping in V28—no longer risk-adjusted.
Neurocognitive disorders (e.g. dementia, Alzheimer’s) remain and expand in granularity:
V24 had 2–4 HCCs; V28 expands to 3 HCCs, refined by severity and behavioral symptoms (HiACode,Medicare & Medicaid Portal).
3. Asthma and COPD
Severe persistent asthma: newly risk-adjusted with HCC 279 (was not captured in V24).
COPD: HCC change from 111 to 280 (broadens across exacerbation types). (HiACode, Blue Cross NC, HiACode, Blue Cross NC).
4. Liver & Gastrointestinal
New HCCs include alcoholic hepatitis,toxic liver disease with hepatitis, malignant pleural effusion, bile duct obstruction.
Eliminated: some ICD‑10 codes like protein-calorie malnutrition, toxic ones, etc. (HiACode, CSI Companies, Blue Cross NC).
5. Kidney Disease
Esrd/dialysis dependency (Z99.2) removed as HCC.
Chronic kidney disease stages 3–5 remapped into HCC 326–329. (HiACode,Blue Cross NC, HiACode).
6. Amputations & Phantom Limb
HCC for amputation (V24 HCC 189) is removed.
Phantom limb syndrome remains (new HCC 409) with pain-depth specificity. (HiACode, Blue Cross NC).
7. Neurological & Cognitive
Expanded from 8 to 12 HCCs — more granularity.
Dementia categories refined by type, severity, and behavioral features. (HiACode, CodingIntel, HiACode).
8. Cardiac and Vascular
Number of heart-related HCCs increased from 3 to about 10, reflecting more detailed conditions.
Some vascular and PVD conditions were removed. (HiACode, Haugen Consulting).
9. Cancer & Blood Disorders
HCCs increased for neoplasms and blood diseases (e.g. HCC count from 5 to 7, and 3 to 7 respectively).
Many remission/non‑remission categories elaborated. (HiACode, Blue Cross NC).
❗ What Conditions Had the Most Change?
Based on mapping shifts, coefficient changes, elimination/additions, and granularity adjustments, the conditions with the most dramatic impact are:
Diabetes – major because of coefficient constraining and consolidation.
Mental health (specifically depression/anxiety) – removed entirely from risk adjustment.
Asthma & COPD – new and redesigned categories change RAF capture.
Kidney disease (dialysis) – removal of dialysis dependency HCC.
Neurology and Dementia – expanded specificity and behavioral detail.
Cancer/Blood disorders – expanded remission states and subtype recognition.
Quantitatively, the biggest net removals/additions were among:
Diabetes (RAF restructure – unified coefficient),
Asthma/COPD (new inclusion & HCC reassignment),
Kidney Disease (removals and reassignments),
Mental Health (removal of mapped depression/anxiety codes),
Neurological and Dementia (expanded HCCs and specificity). (Medicare & Medicaid Portal, MedeAnalytics, Haugen Consulting)
📊 Impact Summary
Domain
Change Type
Impact
Diabetes
Consolidated HCCs, coefficient equalization
RAF reduction for complications
Mental Health
Complete removal of mild/moderate depression
Loss of RAF contribution
COPD & Asthma
New HCC for severe asthma, COPD remapping
New opportunity, shifting population weight
Kidney Disease
Dialysis dependency removed, CKD refined
Potential RAF loss for ESRD patients
Dementia/Neurological
Expanded HCCs, behavioral severity added
Higher granularity, better risk capture
GI & Liver Diseases
New disease codes (e.g. alcoholic hepatitis)
More risk granularity & capture
✅ Next Steps — Recommendations
Analyze Patient Panels
Identify which of your patients shifted categories (e.g., diabetic with complications).
Assess the impact on RAF scores, especially for high-prevalence conditions (diabetes, COPD, CKD, dementia).
Documentation Optimization
Ensure specificity for diabetes, COPD, dementia subtypes, and kidney disease staging.
Include severity or behavioral details where applicable (e.g., “behavioral disturbance” in dementia).
Clinical Education
Train coders and clinicians to avoid relying on removed HCCs (e.g. mild depression, dialysis dependency).
Highlight the most impacted conditions: diabetes, mental health, pulmonary disease, kidney, and neurology.
Model Financial Projections
Prepare for average RAF score reductions (~3.12%) and shifts in condition-level contributions.
Integrate dual-model reporting (V24/V28) during the transition phase (especially 2025).