February 1, 2023
Attachment II. Changes in the Payment Methodology for Medicare Advantage and PACE for CY 2024
<aside> 📔 Table of Contents
| 2020 model (V24) | Proposed model (V28) |
|---|---|
| • 86 payment HCCs | |
| • 9,797 FY22/FY23 ICD-10 diagnosis codes mapped to an HCC for payment | • 115 payment HCCs |
| • 7,770 FY22/FY23 ICD-10 diagnosis codes mapped to an HCC for payment | |
| Infectious Disease Group: 3 HCCs | Infectious Disease Group: 3 HCCs |
| • HCC 1 (HIV/AIDS) | • HCC 1 (HIV/AIDS) |
| • HCC 2 (Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock) | • HCC 2 (Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock) |
| • HCC 6 (Opportunistic Infections) | • HCC 6 (Opportunistic Infections) |
| Neoplasm Disease Group: 5 HCCs | |
| • HCC 8 (Metastatic Cancer and Acute Leukemia) | |
| • HCC 9 (Lung and Other Severe Cancers) | |
| • HCC 10 (Lymphoma and Other Cancers) | |
| • HCC 11 (Colorectal, Bladder, and Other Cancers) | |
| • HCC 12 (Breast, Prostate, and Other Cancers and Tumors) | Neoplasm Disease Group: 7 HCCs |
| • HCC 17 (Cancer Metastatic to Lung, Liver, Brain, and Other Organs; Acute Myeloid Leukemia Except Promyelocytic) | |
| • HCC 18 (Cancer Metastatic to Bone, Other and | |
| Unspecified Metastatic Cancer; Acute Leukemia Except Myeloid) | |
| • HCC 19 (Myelodysplastic Syndromes, Multiple Myeloma, and Other Cancers) | |
| • HCC 20 (Lung and Other Severe Cancers) | |
| • HCC 21 (Lymphoma and Other Cancers) | |
| • HCC 22 (Bladder, Colorectal, and Other Cancers) | |
| • HCC 23 (Prostate, Breast, and Other Cancers and Tumors) | |
| Diabetes Disease Group: 3 HCCs | Diabetes Disease Group: 4 HCCs |
| • HCC 17 (Diabetes with Acute Complications) | • HCC 35 (Pancreas Transplant Status) |
| • HCC 18 (Diabetes with Chronic Complications) | • HCC 36 (Diabetes with Severe Acute Complications) |
| • HCC 19 (Diabetes without Complication) | • HCC 37 (Diabetes with Chronic Complications) |
| • HCC 38 (Diabetes with Glycemic, Unspecified, or No Complications) | |
| Metabolic Disease Group: 3 HCCs | |
| • HCC 21 (Protein-Calorie Malnutrition) | |
| • HCC 22 (Morbid Obesity) | Metabolic Disease Group: 4 HCCs |
| • HCC 48 (Morbid Obesity) | |
| • HCC 49 (Specified Lysosomal Storage Disorders) |
| • HCC 23 (Other Significant Endocrine and Metabolic Disorders) | • HCC 50 (Amyloidosis, Porphyria, and Other Specified Metabolic Disorders) • HCC 51 (Addison's and Cushing's Diseases, Acromegaly, and Other Specified Endocrine Disorders) | | --- | --- | | Liver Disease Group: 3 HCCs | Liver Disease Group: 5 HCCs | | • HCC 27 (End-Stage Liver Disease) | • HCC 62 (Liver Transplant Status/Complications) | | • HCC 28 (Cirrhosis of Liver) | • HCC 63 (Chronic Liver Failure/End-Stage Liver Disorders) | | • HCC 29 (Chronic Hepatitis) | • HCC 64 (Cirrhosis of Liver) • HCC 65 (Chronic Hepatitis) • HCC 68 (Cholangitis and Obstruction of Bile Duct Without Gallstones) | | Gastrointestinal Disease Group: 3 HCCs | Gastrointestinal Disease Group: 5 HCCs | | • HCC 33 (Intestinal Obstruction/Perforation) | • HCC 77 (Intestine Transplant Status/Complications) | | • HCC 34 (Chronic Pancreatitis) | • HCC 78 (Intestinal Obstruction/Perforation) | | • HCC 35 (Inflammatory Bowel Disease) | • HCC 79 (Chronic Pancreatitis) • HCC 80 (Crohn's Disease (Regional Enteritis)) • HCC 81 (Ulcerative Colitis) | | Musculoskeletal Disease Group: 2 HCCs • HCC 39 (Bone/Joint/Muscle Infections/Necrosis) • HCC 40 (Rheumatoid Arthritis and Inflammatory Connective Tissue Disease) | Musculoskeletal Disease Group: 3 HCCs • HCC 92 (Bone/Joint/Muscle/Severe Soft Tissue Infections/Necrosis) • HCC 93 (Rheumatoid Arthritis and Other Specified Inflammatory Rheumatic Disorders) • HCC 94 (Systemic Lupus Erythematosus and Other Specified Systemic Connective Tissue Disorders) | | Blood Disease Group: 3 HCCs • HCC 46 (Severe Hematological Disorders) • HCC 47 (Disorders of Immunity) • HCC 48 (Coagulation Defects and Other Specified Hematological Disorders) | Blood Disease Group: 7 HCCs • HCC 107 (Sickle Cell Anemia (Hb-SS) and Thalassemia Beta Zero) • HCC 108 (Sickle Cell Disorders, Except Sickle Cell Anemia (Hb-SS) and Thalassemia Beta Zero; Beta Thalassemia Major) • HCC 109 (Acquired Hemolytic, Aplastic, and Sideroblastic Anemias) • HCC 111 (Hemophilia, Male) • HCC 112 (Immune Thrombocytopenia and Specified Coagulation Defects and Hemorrhagic Conditions) |
| | • HCC 114 (Common Variable and Combined Immunodeficiencies) • HCC 115 (Specified Immunodeficiencies and White Blood Cell Disorders) | | --- | --- | | Cognitive Disease Group: 2 HCCs | Cognitive Disease Group: 3 HCCs | | • HCC 51 (Dementia With Complications) | • HCC 125 (Dementia, Severe) | | • HCC 52 (Dementia Without Complication) | • HCC 126 (Dementia, Moderate) • HCC 127 (Dementia, Mild or Unspecified) | | Substance Use Disorder Disease Group: 3 HCCs • HCC 54 (Substance Use with Psychotic Complications) • HCC 55 (Substance Use Disorder, Moderate/Severe, or Substance Use with Complications) • HCC 56 (Substance Use Disorder, Mild, Except Alcohol and Cannabis) | Substance Use Disorder Disease Group: 5 HCCs • HCC 135 (Drug Use with Psychotic Complications) • HCC 136 (Alcohol Use with Psychotic Complications) • HCC 137 (Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications) • HCC 138 (Drug Use Disorder, Mild, Uncomplicated, Except Cannabis) • HCC 139 (Alcohol Use Disorder, Moderate/Severe, or Alcohol Use with Specified Non-Psychotic Complications) | | Psychiatric Disease Group: 4 HCCs | Psychiatric Disease Group: 5 HCCs | | • HCC 57 (Schizophrenia) | • HCC 151 (Schizophrenia) | | • HCC 58 (Reactive and Unspecified Psychosis) | • HCC 152 (Psychosis, Except Schizophrenia) | | • HCC 59 (Major Depressive, Bipolar, and Paranoid Disorders) | • HCC 153 (Personality Disorders; Anorexia/Bulimia Nervosa) | | • HCC 60 (Personality Disorders) | • HCC 154 (Bipolar Disorders without Psychosis) | | | • HCC 155 (Major Depression, Moderate or Severe, without Psychosis) | | Spinal Disease Group: 3 HCCs | Spinal Disease Group: 3 HCCs | | • HCC 70 (Quadriplegia) | • HCC 180 (Quadriplegia) | | • HCC 71 (Paraplegia) | • HCC 181 (Paraplegia) | | • HCC 72 (Spinal Cord Disorders/Injuries) | • HCC 182 (Spinal Cord Disorders/Injuries) | | Neurological Disease Group: 8 HCCs • HCC 73 (Amyotrophic Lateral Sclerosis and Other Motor Neuron Disease) • HCC 74 (Cerebral Palsy) | Neurological Disease Group: 12 HCCs • HCC 190 (Amyotrophic Lateral Sclerosis and Other Motor Neuron Disease, Spinal Muscular Atrophy) • HCC 191 (Quadriplegic Cerebral Palsy) • HCC 192 (Cerebral Palsy, Except Quadriplegic) | | • HCC 75 (Myasthenia Gravis/Myoneural Disorders and Guillain-Barre Syndrome/Inflammatory and Toxic Neuropathy) • HCC 76 (Muscular Dystrophy) • HCC 77 (Multiple Sclerosis) • HCC 78 (Parkinson's and Huntington's Diseases) • HCC 79 (Seizure Disorders and Convulsions) • HCC 80 (Coma, Brain Compression/Anoxic Damage) | • HCC 193 (Chronic Inflammatory Demyelinating Polyneuritis and Multifocal Motor Neuropathy) • HCC 195 (Myasthenia Gravis with (Acute) Exacerbation) • HCC 196 (Myasthenia Gravis without (Acute) Exacerbation and Other Myoneural disorders) • HCC 197 (Muscular Dystrophy) • HCC 198 (Multiple Sclerosis) • HCC 199 (Parkinson and Other Degenerative Disease of Basal Ganglia) • HCC 200 (Friedreich and Other Hereditary Ataxias; Huntington Disease) • HCC 201 (Seizure Disorders and Convulsions) • HCC 202 (Coma, Brain Compression/Anoxic Damage) | | Arrest Disease Group: 3 HCCs | Arrest Disease Group: 3 HCCs | | • HCC 82 (Respirator Dependence/Tracheostomy Status) | • HCC 211 (Respirator Dependence/Tracheostomy Status/Complications) | | • HCC 83 (Respiratory Arrest) | • HCC 212 (Respiratory Arrest) | | • HCC 84 (Cardio-Respiratory Failure and Shock) | • HCC 213 (Cardio-Respiratory Failure and Shock) | | Heart Disease Group: 5 HCCs • HCC 85 (Congestive Heart Failure) • HCC 86 (Acute Myocardial Infarction) • HCC 87 (Unstable Angina and Other Acute Ischemic Heart Disease) • HCC 88 (Angina Pectoris) • HCC 96 (Specified Heart Arrhythmias) | Heart Disease Group: 10 HCCs • HCC 221 (Heart Transplant Status/Complications) • HCC 222 (End Stage Heart Failure) • HCC 223 (Heart Assist Device/Artificial Heart)1 • HCC 224 (Acute on Chronic Heart Failure) • HCC 225 (Acute Heart Failure (Excludes Acute on Chronic)) • HCC 226 (Heart Failure, Except End Stage and Acute) • HCC 227 (Cardiomyopathy/Myocarditis) • HCC 228 (Acute Myocardial Infarction) • HCC 229 (Unstable Angina and Other Acute Ischemic Heart Disease) |
| • HCC 238 (Specified Heart Arrhythmias) | |
|---|---|
| Cerebrovascular Disease Group: 4 HCCs | Cerebrovascular Disease Group: 4 HCCs |
| • HCC 99 (Intracranial Hemorrhage) | • HCC 248 (Intracranial Hemorrhage) |
| • HCC 100 (Ischemic or Unspecified Stroke) | • HCC 249 (Ischemic or Unspecified Stroke) |
| • HCC 103 (Hemiplegia/Hemiparesis) | • HCC 253 (Hemiplegia/Hemiparesis) |
| • HCC 104 (Monoplegia, Other Paralytic Syndromes) | • HCC 254 (Monoplegia, Other Paralytic Syndromes) |
| Vascular Disease Group: 3 HCCs | Vascular Disease Group: 3 HCCs |
| • HCC 106 (Atherosclerosis of the Extremities with Ulceration or Gangrene) | • HCC 263 (Atherosclerosis of Arteries of the Extremities with Ulceration or Gangrene) |
| • HCC 107 (Vascular Disease with Complications) | • HCC 264 (Vascular Disease with Complications) |
| • HCC 108 (Vascular Disease) | • HCC 267 (Deep Vein Thrombosis and Pulmonary Embolism) |
| Lung Disease Group: 5 HCCs | |
| • HCC 110 (Cystic Fibrosis) | |
| • HCC 111 (Chronic Obstructive Pulmonary Disease) | |
| • HCC 112 (Fibrosis of Lung and Other Chronic Lung Disorders) | |
| • HCC 114 (Aspiration and Specified Bacterial Pneumonias) | |
| • HCC 115 (Pneumococcal Pneumonia, Empyema, Lung Abscess) | Lung Disease Group: 7 HCCs |
| • HCC 276 (Lung Transplant Status/Complications) | |
| • HCC 277 (Cystic Fibrosis) | |
| • HCC 278 (Idiopathic Pulmonary Fibrosis and Lung Involvement in Systemic Sclerosis) | |
| • HCC 279 (Severe Persistent Asthma) | |
| • HCC 280 (Chronic Obstructive Pulmonary Disease, Interstitial Lung Disorders, and Other Chronic Lung Disorders) | |
| • HCC 282 (Aspiration and Specified Bacterial Pneumonias) | |
| • HCC 283 (Empyema, Lung Abscess) | |
| Eye Disease Group: 2 HCCs | Eye Disease Group: 2 HCCs |
| • HCC 122 (Proliferative Diabetic Retinopathy and Vitreous Hemorrhage) | • HCC 298 (Severe Diabetic Eye Disease, Retinal Vein Occlusion, and Vitreous Hemorrhage) |
| • HCC 124 (Exudative Macular Degeneration) | • HCC 300 (Exudative Macular Degeneration) |
| Kidney Disease Group: 5 HCCs | Kidney Disease Group: 4 HCCs |
| • HCC 134 (Dialysis Status) | • HCC 326 (Chronic Kidney Disease, Stage 5) |
| • HCC 135 (Acute Renal Failure) | • HCC 327 (Chronic Kidney Disease, Severe (Stage 4)) |
| • HCC 136 (Chronic Kidney Disease, Stage 5) | • HCC 328 (Chronic Kidney Disease, Moderate (Stage 3B)) |
| • HCC 137 (Chronic Kidney Disease, Severe (Stage 4)) | • HCC 329 (Chronic Kidney Disease, Moderate (Stage 3, Except 3B)) |
| • HCC 138 (Chronic Kidney Disease, Moderate (Stage 3)) | |
|---|---|
| Skin Disease Group: 5 HCCs | |
| • HCC 157 (Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone) | |
| • HCC 158 (Pressure Ulcer of Skin with Full Thickness Skin Loss) | |
| • HCC 159 (Pressure Ulcer of Skin with Partial Thickness Skin Loss) | |
| • HCC 161 (Chronic Ulcer of Skin, Except Pressure) | |
| • HCC 162 (Severe Skin Burn or Condition) | Skin Disease Group: 7 HCCs |
| • HCC 379 (Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone) | |
| • HCC 380 (Chronic Ulcer of Skin, Except Pressure, Through to Bone or Muscle) | |
| • HCC 381 (Pressure Ulcer of Skin with Full Thickness Skin Loss) | |
| • HCC 382 (Pressure Ulcer of Skin with Partial Thickness Skin Loss) | |
| • HCC 383 (Chronic Ulcer of Skin, Except Pressure, Not Specified as Through to Bone or Muscle) | |
| • HCC 385 (Severe Skin Burn) | |
| • HCC 387 (Pemphigus, Pemphigoid, and Other Specified Autoimmune Skin Disorders) | |
| Injury Disease Group: 5 HCCs | |
| • HCC 166 (Severe Head Injury) | |
| • HCC 167 (Major Head Injury) | |
| • HCC 169 (Vertebral Fractures without Spinal Cord Injury) | |
| • HCC 170 (Hip Fracture/Dislocation) | |
| • HCC 173 (Traumatic Amputations and Complications) | Injury Disease Group: 6 HCCs |
| • HCC 397 (Major Head Injury with Loss of Consciousness > 1 Hour) | |
| • HCC 398 (Major Head Injury with Loss of Consciousness < 1 Hour or Unspecified) | |
| • HCC 399 (Major Head Injury without Loss of Consciousness) | |
| • HCC 401 (Vertebral Fractures without Spinal Cord Injury) | |
| • HCC 402 (Hip Fracture/Dislocation) | |
| • HCC 405 (Traumatic Amputations and Complications) | |
| Complications Disease Group: 1 HCC | |
| • HCC 176 (Complications of Specified Implanted Device or Graft) | Complications Disease Group: 0 HCCs |
| Amputation Disease Group: 1 HCC | |
| • HCC 189 (Amputation Status, Lower Limb/Amputation Complications) | Amputation Disease Group: 1 HCC |
| • HCC 409 (Amputation Status, Lower Limb/Amputation Complications) | |
| Transplant Disease Group: 1 HCC | Transplant Disease Group: 1 HCC |
| • HCC 186 (Major Organ Transplant or Replacement Status) | • HCC 454 (Stem Cell, Including Bone Marrow, Transplant Status/Complications) |
| Openings Disease Group: 1 HCC | |
| • HCC 188 (Artificial Openings for Feeding or Elimination) | Openings Disease Group: 1 HCC |
| • HCC 463 (Artificial Openings for Feeding or Elimination) |
<aside> 💡 HCC 223 Heart Assist Device/Artificial Heart contains six ICD-10 codes for presence or complications of heart assist device and artificial heart. To capture only beneficiaries with heart failure (versus an acute condition),
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<aside> 💡 HCC 223 is further restricted to beneficiaries who also have an ICD-10 code mapping to heart failure HCCs 224, 225, or 226. Beneficiaries without a heart failure code will not be assigned to HCC 223.
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<aside> 💡 Beneficiaries with codes for heart transplant status/complications or for end stage heart failure will be assigned to HCC 221 Heart Transplant Status/Complications or HCC 222 End Stage Heart Failure, respectively.
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<aside> 💡 Coefficients (relative risk factors) for HCC 223 and HCC 222 are constrained equal.↩
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