Navigating CMS-HCC Version 28: Compliance and Understanding the RAF Score

As the healthcare landscape evolves, staying updated with CMS-HCC versions is crucial for accurate reimbursement and compliance. Drawing on my extensive experience at Dagger Healthcare Solutions, we are here to guide you through CMS-HCC Version 28, shedding light on compliance and demystifying the Risk Adjustment Factor (RAF) score. In this article, we'll explore the key aspects of CMS-HCC Version 28 and provide actionable steps to ensure compliance and optimize your RAF score.

Understanding CMS-HCC Version 28: CMS-HCC is a risk adjustment model used to predict healthcare expenditures. Version 28 introduces updates to diagnostic categories, refining the accuracy of risk adjustment. CMS made significant changes to the structure of the HCC model in Version 28 (V28), which will impact RAF scores for a large percentage of Medicare Advantage beneficiaries. These changes include:

• How the V28 HCC codes are named and numbered

• An expanded number of HCCs

• Changes to ICD-10-CM code to HCC mappings

• Changes to the HCC coefficient values

• Removal of 2,294 diagnosis codes that no longer map to a payment HCC

• Addition of 268 diagnosis codes that did not map to a payment CMS-HCC in V24

Key Steps to Ensure Compliance with CMS-HCC Version 28:

1. Stay Informed: Regularly review CMS communications and updates to ensure you're aware of any changes in CMS-HCC Version 28.

2. Accurate Documentation: Providers must ensure that documentation supports the submitted codes, reflecting the true health status of the patient.

3. Coding Precision: Accurate coding of diagnoses and conditions is pivotal for proper risk adjustment and RAF score calculation.

4. Timely Reporting: Submit claims and reports accurately and on time to ensure proper risk assessment.

Demystifying the RAF Score: The RAF score reflects the health status of a patient population, impacting reimbursement rates. A higher RAF score indicates a sicker population and potentially higher reimbursement.

Optimizing Your RAF Score:

1. Complete Documentation: Ensure comprehensive documentation that reflects all relevant diagnoses and conditions.

2. Accurate Coding: Precise coding is essential to accurately reflect patient conditions and calculate the RAF score.

3. Continuous Review: Regularly audit coding and documentation practices to identify areas for improvement.

 Dagger Healthcare Solutions' Support:

At Dagger Healthcare Solutions, we understand the intricacies of CMS-HCC Version 28 and its impact on risk adjustment and reimbursement. Our experts offer:

• Compliance Audits: We conduct thorough audits to ensure accurate coding and documentation practices.

• Coding Training: We provide coding training and education to ensure compliance and optimal RAF scores.

CMS-HCC Version 28 presents opportunities and challenges in risk adjustment and reimbursement. The overall impact of the proposed changes on beneficiary RAF scores will depend on several factors, however RAF score in general will likely decline. CMS projects that the CY 2024 impact on MA risk scores of the proposed Part C CMS-HCC model is projected to be -3.12%. This projects to $11.0 billion in net savings to the Medicare Trust fund in 2024.  Actual PMPM payment amounts are based on multiple additional factors. Dagger Healthcare Solutions stands ready to guide your organization in navigating the complexities, ensuring compliance, accurate documentation, and optimal RAF scores for financial stability and quality care.