Accuracy is everything in medicine.

By capturing a patient’s conditions with specificity for payors, your patients get the care, medicine and attention they need to live their healthiest lives.  

That’s simple in theory — it gets more complicated in practice. And now with CMS ushering in the transition from HCC model v24 to v28, the things you need to know to be as accurate and compliant as possible have only grown. 

Gaps in clinical documentation have real consequences for patients. 

Perhaps you’ve seen situations like these stories: 

• A patient who needed authorization for an electric wheelchair but was denied for lack of proper amputation complication codes.  

• A patient incorrectly coded for diabetes is flagged for unnecessary follow-ups.  

• A patient appears to have a reported condition because a provider used a condition code even though diagnostic testing was negative. 

Is clinical documentation frustrating? Yes. 

But is it simply a bureaucratic headache? No. 

Accurately tracking the condition of your patients through Hierarchical Condition Category (HCC) codes takes time and expertise. We recognize you may be short on both.   

That’s why we’ve got you covered. 

Change is scary when you don’t see it coming.

Let’s start by breaking down some of the overarching changes as we move from v24 to v28:

• HCCs increase from 86 to 115 

• Nearly 3,000 HCC ICD-10 codes removed  

• 268 ICD-10 HCC added 

• Changes to ICD-10-CM to HCC mapping 

• Changes in coefficient values 

• Moderate and Severe status is heightened

Key conditions impacted include: 

• Vascular (negative impact) 

• Psychiatric (negative impact) 

• Neoplasms, Heart, Lung and Kidney (positive impact) 

Source – “Proposed MA Risk Adjustment Model - Good News for Some, Detrimental for Others”, Brian Machut and Rachel Stewart, March 2023.  Vascular Risk score impact projected to fall from 0.065 to 0.014 (79% decline), Psychiatric risk score impact projected to fall from 0.037 to 0.019 (50% decline). 

Let’s chart a path forward.  

Many common conditions are affected. In the chart below, notice the risk score fluctuation across 26 major disease groups from v24 to v28.  

3 Watch Outs

1. Avoid using the unspecified or “other” code when a more specified code should be used to report the condition.   

2. Watch out for noting an active condition when the documentation supports that the condition was resolved. 

3. Never document a condition without showing your work. Always include a supporting treatment plan.

6 Tips to Hyperdrive Accuracy 

1. Document all applicable HCC conditions at least once per year. 

2. Be aware of new HCC categories that require the highest specificity code to be identified as an HCC, such as: 

   • Chronic Kidney Disease — Document accurate stage at time of the visit 

   • Diabetic Retinopathy — Document if proliferative and if with macular edema 

   • Major Depression, Bipolar, Schizophrenia — Document severity of the condition 

   • Peripheral Vascular Disease — Document associated rest pain or ulcers

3. Review the common diagnoses that now map to an HCC: 

   • Alcoholic Hepatitis 

   • Anorexia 

   • Benign Carcinoid Tumors 

   • Central Retinal Vein Occlusion 

   • Macular Edema 

   • Obstruction of Bile Duct 

   • Severe Persistent Asthma 

4. Document any disease interactions since they carry additional value coefficients, such as: 

   • Chronic Kidney Disease and CHF  

   • COPD and CHF 

   • Diabetes and CHF 

   • Heart Arrhythmia and CHF 

5. Capture any metastatic disease for patients that have active cancers.  

6. Continue to document any HCC that were assigned a value in v24 and have not yet been assigned a value in v28. They will have their current value until 2025. 

Clinical documentation is no different than learning a foreign language. Many have been getting by on a basic understanding. There’s no better time to step up to fluency.  

Wellvana has native speakers who will help you through it all. 

Wellvana offers on-demand assistance to all of its ACO members. 

You can’t learn everything about the v28 transition in one article. You need a trusted partner to get in the trenches with you.  

Ensuring conditions are properly captured for payors as accurately as possible is a cornerstone of value-based care success. Wellvana’s different than the typical hands-off Accountable Care Organization (ACO) – we offer on-demand clinical documentation education, from quick Q&As to more immersive workshops, all at the convenience of our ACO members.