By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA
In the risk adjustment model used by Medicare Advantage and other insurers, ICD-10-CM diagnosis codes are mapped to the Hierarchical Condition Category (HCC) and the associated coefficients (weights assigned based on residency, payer coverage, etc.) are used to calculate the level of health plan reimbursement for that HCC. Both how these codes are mapped and their coefficients change from year to year. Coders need to know how the diagnosis codes are mapped for the period being reviewed.
I have had several individuals reach out to me during 2021 asking where the new HCC Map and Coefficients are. Thinking I may have missed something, I, too, did an exhaustive search for them. After reading a number of articles on the Internet and government announcements, in April 2021, I reached out to the Risk Adjustment Policy Team at CMS. Their response appears below.
From The CMS Risk Adjustment Policy Team
- For PY2021, as we described in the 2021 Announcement, CMS will blend 25% of the risk score using the 2017 CMS-HCC model using diagnoses from RAPS and FFS, summed with 75% of the risk score calculated with the 2020 CMS-HCC model using diagnoses from encounter data, RAPS inpatient records, and FFS.
- For PY 2022, as we described in the 2022 Announcement, CMS will complete phasing in the 2020 CMS-HCC model (previously known as the alternative payment condition count or APCC model) which will be used with no blending for the risk score calculation. Specifically, 100 percent of the risk score will be calculated with the 2020 CMS-HCC model.
- For the 2017 CMS-HCC model relative factors, please reference attachment VI in the 2017 Announcement.
- For the 2020 CMS-HCC model relative factors, please reference attachment VI of the 2020 Announcement.
For 2022, I repeated the process of reading articles on the Internet and government bulletins, only to once again find no new Map and Coefficients, other than this link, which coincidentally was also provided to me by General Dynamics Health Solutions in response to one of my online inquiries. When you click on the 2022 Map, it reflects the 2020 (and 2021) Map.
Recently, RCxRules, reconfirmed what the Risk Adjustment Policy Team at CMS told me earlier in 2021: the same Map (and coefficients) will be used for 2022 until the phase-in of the new model responding to the 21st Century Cures Act is completed. Additionally, RCxRules provided a link to the CY 2020 Announcement. The coefficient values start on page 73
So, if you have been beating yourself up, looking for the current or next year’s Map and Coefficients…STOP! I hope this information is helpful to you.
HCC: Auditing in the Risk Adjustment Environment
Internal HCC auditors: get the essential information you need to ensure your organization receives proper reimbursement — and that codes and claims are supported by clinical documentation.
Learn what to look for and how to communicate your findings. Tips and techniques offered by nationally recognized HCC authority Rose T. Dunn! Learn more here.