Section J. CMS-HCC Risk Adjustment Model for CY 2024

<aside> 💡 Details of Disease Groups and HCC Updates based on Principle 10 are extracted from Rate Announcement Section J (page 65 to page 115).

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<aside> 📔 Table of Contents

• Open Me! </aside>

Clinical Panel

To obtain clinical input throughout the model development process, CMS consulted with a panel of internal medicine and general practitioners to provide clinical expertise, as the model covers all body systems and a broad spectrum of diagnoses. The clinicians are practicing physicians, as well as professors, and health services researchers. A series of discussions with the clinicians were held over the course of a year to review and discuss the reclassification.

The reclassification process, including the clinical consultation panel review, is an iterative process.

The process involves empirical data investigation and analysis by healthcare economists, clinical research, and clinician input and review. Multiple iterations of the model are calibrated to evaluate diagnosis mappings, HCC reconfigurations, clinical hierarchies, and which HCCs are included in the model for payment.

Clinician input was provided, where applicable, for each model iteration.

<aside> 💡 Decisions regarding the model classification (e.g., how diagnoses are grouped) were made based on the level of granularity provided in the ICD-10 classification system, the risk adjustment model principles, examination of the model performance (i.e., predictive accuracy), and for the initial analysis to further assess which conditions are more discretionary, a review of HCC frequencies in MA and FFS.

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The clinical panel provided insight and recommendations related to:

• [ ] the criteria used to evaluate and treat conditions (e.g., lab findings, test results, physical exams, medications, medical interventions, etc.);
• [ ] specificity of diagnoses;
• [ ] potential for variable coding for certain diseases or disease groups;
• [ ] treatment practices;
• [ ] manifestations of conditions in different populations (e.g., aged vs. disabled; non-dual vs. full-benefit; dual vs. partial-benefit dual);
• [ ] disease severity and implications for medical burden;
• [ ] the need for additional medical specialist intervention (i.e., whether or not a condition would require evaluation by a specialty clinician);