The transition from HCC Model V24 to V28 is causing a significant change for healthcare providers. More than merely a legislative change, this risk adjustment model update has a direct influence on Risk Adjustment Factor (RAF) scores, changes reimbursement structures, and necessitates a new degree of documentation accuracy. These modifications may result in lower compensation and more compliance concerns if not appropriately handled. Staying ahead in the rapidly changing healthcare market requires an understanding of the ramifications and the ability to adjust to them.

The Timeline for the Transition: When Will V28 Fully Implement?

To facilitate the transition, CMS has implemented a phased rollout, allowing organizations to modify their reporting and coding procedures. The following is the timeline:

• 2023: 33% V28 and 67% V24
• 2024: 67% V28 and 33% V24
• 2025: 100% V28

Providers need to be completely on board with the new model by 2025. Financial setbacks and documentation problems might result from not making the required modifications in advance.

Significant Modifications to HCC Model V28

Changes to ICD-10 Code Mapping: What’s New and What’s Gone

The elimination of 2,294 ICD-10 codes that were formerly linked to HCCs is one of the most important changes in V28. This implies that many ailments that previously affected a patient’s RAF score might no longer be taken into account. Coding teams need to be aware of these deletions and find alternate documentation solutions to preserve accuracy and prevent revenue loss.

Constrained Coefficients for Common Conditions: The Reasons Some Diagnoses Are Not as Important

Chronic diseases with limited coefficients under V28 include diabetes, heart failure, COPD, major depressive disorder, and bipolar disorder. All HCCs within these categories are given the same weight rather than varying weights according to severity or comorbidity.

This change may result in lower RAF scores and reduced reimbursements for certain patients, particularly if their diseases were previously classified in ways that led to greater compensation. To counteract any cutbacks, organizations will need to concentrate on obtaining the complete clinical picture.

RAF Score Adjustments: Who Gains and Who Loses?

Relative factors in V28 will be higher for certain disorders and lower for others, which will affect a patient’s total RAF score. Let’s examine several instances:

Comparisons of Case Studies

Example 1: A man with diabetes who is 67 years old, because HCC Model V24 has several HCC categories for various diabetic conditions, this patient may have received a higher RAF score. V28’s RAF score may be lower as a result of combining these diseases, which might have an impact on reimbursement.

Example 2: Individuals with Several Chronic IllnessesDue to the greater weighting of immune diseases and chronic ulcers in V28, a patient with these illnesses is likely to have a higher RAF score.

Adapting to V28: Strategies for Optimizing Revenue

Providers should take the following proactive measures to reduce financial risks and preserve compliance:

• Ensure Accurate and Specific Documentation:

Thorough documentation is necessary for the elimination of thousands of ICD-10 codes. Doctors and coding teams are responsible for making sure that diagnoses are recorded as clearly as possible.

• Regularly Train Coding and Billing Teams:

Missed reimbursements might result from a lack of knowledge. HCC Model V28 training must be ongoing to keep up with these developments.

• Leverage Technology for Risk Adjustment:

AI-powered solutions may be used to find missing HCCs, find gaps in documentation, and improve predictive analytics to maximize RAF ratings.

• Perform Internal Audits and Risk Assessments

Regular auditing can assist in identifying mistakes before they result in revenue losses or claim denials. Examining past claims proactively might reveal trends and opportunities for development.

How Persivia Aids in Providers’ Continued Success

Although moving from HCC Model V24 to V28 might be challenging, Persivia CareSpace® provides the resources required to make compliance easier. The brand offers real-time data insights, AI-driven coding solutions, and new risk adjustment model algorithms to assist providers in:

• Continue to compute RAF scores accurately.
• Boost the correctness of the documentation and coding
• Simplify processes to improve income and compliance.

Bottom Line 

A significant change to risk adjustment techniques is represented by the switch to HCC Model V28. Providers need to respond immediately due to limited coefficients, a redesigned RAF calculation, and a large number of eliminated ICD-10 codes. Organizations may effectively move without experiencing financial or compliance setbacks by improving documentation standards, leveraging sophisticated analytics, and keeping up with CMS improvements.