The healthcare industry is undergoing constant evolutions to keep aligned with the technological advancements and changing requirements of the patients. The Centres for Medicare and Medicaid Services (CMS) has recently made some noticeable changes in Hierarchical Condition Categories (HCC) coding for Risk Adjustment. Getting implemented in 2024, the new model for risk assessment reduced the number of risk-adjustable codes by more than 2000. This latest version of coding is expected to cause impactful disruption in healthcare risk assessment. This new VersionVersion will lead to a reduction in the risk score as a whole. The article majorly focuses on the differences between Version 28 and Version 24 of the HCC coding model for CMS risk adjustment and how they will impact the healthcare industry.
The Differences between Version 24 And Version 28
There are significant differences between the recent VersionVersion of the risk adjustment model laid down by the CMS. Let’s delve into the significant dissimilarities between the two –
- The Number Of Codes – The biggest difference between the two versions is the number of ICD risk-adjustable codes. The obsolete VersionVersion had 7,320 ICD codes, while the new Version 28 includes 4,958 codes. This implies the reduction of 32% codes in the current VersionVersion as compared to the previous one. The significant reduction is bound to change the approach of the payers and services providers towards risk adjustment.
- Emphasis On Recording Chronic Conditions – The renewed model for risk adjustment coding will focus more on chronic condition documentation. The calculation of the Risk Adjustment Factor (RAF) under the new guidelines will increase the focus on beneficiaries with chronic health conditions. Documentation of the former is essential for accuracy in risk adjustment. Providers need to look after complete and appropriate documentation to save themselves from any financial penalties.
- A Different Technology – The previous coding models worked on a defined technology but with the new evolutions in the coding model, the payers are required to deploy an advanced technology that caters to the accuracy while complying with the framework. The new system must offer accurate results and seamless management of the data. The payers must focus on different strategies to ensure the adaptation of their systems to constant evolutions.
- Difference In Risk Adjustment Scores – Version 28 of the coding model is also going to impact the risk scores and payments. With a reduction in the number of codes in the new risk management system, there will be less risk scores given to the beneficiaries. This implies that there will be a decrease in the amount of reimbursed funds. Hence, the providers will need to focus more on recording chronic diseases to avail themselves of proper funding that will save them revenue generation.
The latest model for risk-adjustment certainly shows a noticeable shift in the risk-assessment for health care. A decrease in the number of risk-adjustable codes is bound to offer significant challenges to both payers and providers. To look after the right care and funding, the providers must do accurate documentation. The payers must deploy latest systems that are competent for managing the associated data with the underlying changes.
Accurate Documentation – A Must For The Healthcare Service Industry
As discussed above, appropriate documentation is a must for the payers and medical service providers to get appropriate reimbursements. This implies a direct impact on the revenue of the organization. Let’s explore a few benefits for a proper documentation –
- An Accurate Coding – A proper documentation required consistent maintenance of the patient health records. HCC coding team needs proper and relevant documentation for elimination of errors while performing coding as it may lead to inaccurate disbursal of funds.
- Data Formats – The patient data must be in a refined format to avoid any confusion while maintaining the health records. The scattered sources meant to capture the holistic health status of the patient, and improper flow of work hamper the clinical documentation and mess up with the funding.
- Proper Claims For Risk Adjustment – The documentation must focus on recording the medical history as well as the lifestyle data while working towards the patient records. A lack in the comprehensive insights on patients’ medical conditions can lead to appropriation in the risk assessment.
- Standardized Data Analysis – Deployment of standardized and advanced tools for calculation of risk assessment can significantly improve the accuracy and this will ultimately lead to appropriate reimbursement.
- Compliance With The Framework – With a proper recording and maintenance of clinical documents in regular time intervals, there’s an automatic compliance of the legal framework. Besides, it eliminates the delay in health care networks in justifying the admission and the medical aid.
Now we know that documentation plays a herculean role in the correctness of HCC coding, which ensures an in-time submission of records to CMS. Besides, it aids in the reduction of any fraudulent activity due to accurate representation of a patient’s health condition and achieving compliance with ROI.
Conclusion
The providers must look after appropriate documentation to escape any issues with appropriate funding. This enables them to look after a standardized medical service while complying with the regulations laid down by CMS. The healthcare organization must have a robust system that streamlines the workflow. Next, they should choose comprehensive risk adjustment software that cover both prospective and retrospective requirements.