To Mitigate Transition Of

HCC Mapping (V24-V28)

Sindhu MD, CPC, CEMC
 Disclaimer
This presentation is designed to offer basic information for coding
and billing. The information presented here is based on the
experience, training and interpretation of the author. Although the
information has been carefully researched and checked for
accuracy and completeness, the instructor does not accept any
responsibility or liability with regard to errors, omissions, misuse
or misinterpretation. This material is intended as an Educational
guide and should not be considered a legal/consulting opinion.
 Learning Objectives
❖Introduction to HCC
❖Origin of Version 24 HCC Model
❖Transition to Version 28 HCC Model
❖Significant Changes in V28 Model
❖Extended HCC categories of V28
❖HCC Mapping Excel
❖Risk Score Calculation
❖Sample Coding
❖Summary
 Introduction to HCC
➢ Hierarchical condition category (HCC) coding is a risk-adjustment model originally designed to
estimate future health care costs for patients
➢ HCC coding relies on ICD-10-CM coding to assign risk scores to patients. Each HCC is mapped to
an ICD-10-CM code. Along with demographic factors such as age and gender, insurance
companies use HCC coding to assign patients a risk adjustment factor (RAF) score
➢ Using algorithms, insurance companies can use a patient’s RAF score to predict costs. For
example, a patient with few serious health conditions could be expected to have average medical
costs for a given time. However, a patient with multiple chronic conditions would be expected to
have higher health care utilization and costs
➢ Centers for Medicare and Medicaid Services (CMS) uses the CMS-HCC risk adjustment model for
the Medicare Advantage program and those who qualify for Medicare or patients 65 and older,
calculating risk payments for the next year
Introduction to HCC
 Introduction to HCC
➢ HCC coders must thoroughly report on each patient’s risk adjustment diagnosis and must be
based on clinical medical record documentation from a face-to-face encounter
➢ Benefits of HCC Model:
• To predict future cost expenditure of patients
• CMS uses HCCs to reimburse Medicare Advantage plans based on the health of their members

➢ Accurate coding is essential for characterizing the risk of the patient. When documentation does
not allow for accurate coding, health plans do not receive the data needed to adequately fund the
patient’s care. Incorrect risk levels ultimately affect patient care and provider payment
➢ The coding is achieved through MEAT concept, i.e.., certified coders validate the record for
Provider’s evaluation of the respective chronic condition documented in Assessment, Problem list,
PMH etc
 Introduction to HCC

Monitor Evaluate
Test results, medication
Signs, symptoms, disease
effectiveness, response to
progression, disease regression
treatment

MEAT
Assess/Address Treatment
Ordering Tests, discussion, review Medications, therapy and other
records, counselling modalities
 Origin of Version 24 HCC Model
• The HCC V24 model was structured using ICD 9 CM codes and being translated to ICD 10 CM
codes, encompassing a total of 9,797 codes under 86 HCC categories
• These codes covered a wide range of medical conditions, procedures, and other healthcare-
related nuances, providing a comprehensive framework for healthcare providers and coders
• The CMS HCC risk adjustment V24 model includes 86 HCC group categories for chronic
illnesses. Here are the most common chronic conditions for Medicare patients:
➢ Hypertension
➢ Hyperlipidemia
➢ Arthritis
➢ Diabetes
➢ Depression
➢ Heart Failure
➢ COPD
➢ Alzheimer’s / Dementia
 Transition to Version 28 HCC Model
➢ V28 introduced new Hierarchical Condition Categories (HCCs) that were not present in the
previous versions. These new HCCs aim to capture more specific health conditions and provide a
more accurate prediction of healthcare costs
➢ Some of the existing HCCs were revised in V28. This revision was done to ensure that the HCCs
remain relevant and accurately represent the health conditions of the beneficiaries
➢ The number of HCC categories will increase from 86 to 115, and categories are renumbered
➢ A change to a very commonly reported condition is diabetes, which has decreased values in V28.
Some categories are eliminated entirely
➢ The change will very likely decrease overall risk scores
 Transition to Version 28 HCC Model
V24 Coefficients V28 Coefficients
Community, Non Community, Non
Dual, Aged Age 70-74 years Dual, Aged Age 70-74 years
Beneficiary Beneficiary
Protein Calorie Protein Calorie
HCC 21 0.455 n/a
Malnutrition Malnutrition
HCC 96 Atrial Fibrillation 0.268 HCC 238 Atrial Fibrillation 0.299
HCC 18/HCC 108 Diabetes with PVD 0.302+0.288 HCC 37 Diabetes with PVD 0.166
HCC 85 Chronic Systolic CHF 0.331 HCC 226 Chronic Systolic CHF 0.36
HCC 189 Toe Amputation 0.519 Toe Amputation n/a
Dx Interaction
Dx Interaction DM+CHF 0.121 0.112
DM+CHF
Dx Interaction CHF+A
Dx Interaction CHF+A Fib 0.085 0.077
Fib
6 HCC (Condition count 4 HCC (condition
0.077 n/a
Factor) Count factor)
Total V24 Disease Total V28 Disease
coefficient Risk coefficient Risk
Score: 2.446 Score: 1.014
 Transition to Version 28 HCC Model
➢ Fast forward to 2024, the V28 model, set to be the standard for this year, has been refined
and now includes 7,770 codes. This is a reduction of over 2,000 codes, representing a
significant streamlining effort.

V24 HCC Model V28 HCC Model

Originated with ICD 9 CM Codes
Total ICD 9,797 codes
86 HCC categories
DM has higher weightage in V24 Model
Mostly includes chronic diagnosis
Originated with ICD 10 CM codes
Total ICD 7,770 codes
115 HCC categories
DM has decreased values in V28.
This model also includes perinatal and congenital
diagnosis codes.

Demographic factors does a vital role in V24 Demographic factors also play a vital role in V28
 Transition to Version 28 HCC Model

➢ Will version V28 change our current ➢ No, The MEAT concept remains same.
diagnosis coding practices? ➢ New diagnosis codes are added into HCC
category and some of the existing HCC categories
are renumbered.
Transition to Version 28 HCC Model
 Transition to Version 28 HCC Model

Bulimia Nervosa
Transition to Version 28 HCC Model
 Transition to Version 28 HCC Model
Severe Persistent Asthma
 Significant changes in V28
➢ Most affected HCC include categories 134, 176, 189 and 23
HCC 134 - Dialysis Status

➢ With reference to Slide no 8, All diagnosis codes

classified under HCC 134 are no longer HCC in
version 28 model

➢ According to version 28 HCC model, dependence

of renal dialysis status and its complication were
categorized as non-payment HCC
HCC 176 - Complication of specified implanted device or Graft

➢ HCC 176-Complications of Specified Implanted

Device or Graft has been completely eradicated from
Version 28 HCC model

➢ The complications of implanted device like

orthopedic prosthetic joint, internal fixation device
earned a payment in V24 HCC model

➢ All these complication diagnosis no longer receives

payment in V28 HCC model
 HCC 189 - Amputation Status, Lower Limb/Amputation
Complications

➢ Complete/partial amputation with subsequent/sequalae encounter has been eradicated

from V28 HCC model
➢ The most captured HCC (Z89.411- Z89.429) receives no payment in V28 model
HCC 189 - Amputation Status, Lower Limb/Amputation
Complications
➢ The HCC category description has not changed
from Version 24 to version 28 model but almost 250
codes have eradicated from HCC 189 category

➢ The subsequent and sequalae encounter of

complete/partial amputation of toes, foot, shoulder,
forearm, finger has been declared as no payment
HCC effective in Version 28 model

➢ Encounter for fitting and adjustment of artificial leg

(Z44.10- to Z44.12-) still receives payment for HCC
in V28

➢ The diagnosis codes (Z89.43- to Z89.6-) also

receives payment for HCC in V28

➢ The complications of amputation stump still receives

payment in V28 model
HCC 23 - Other Significant Endocrine and Metabolic Disorders

➢ Approximately 178 codes have been removed from HCC 23 in Version 28 model

➢ The commonly encountered ICDs from HCC 23 which no longer map to HCC include
hyperaldosteronism, hyperparathyroidism, Cushing syndrome, adrenocortical insufficiency,
postprocedural hypoparathyroidism, postprocedural hypopituitarism and secondary
hyperparathyroidism of renal origin

➢ Below are some list of codes which are no longer HCC

HCC 23 - Other Significant Endocrine and Metabolic Disorders

CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28

A391 Waterhouse-Friderichsen syndrome 23 No longer HCC

D891 Cryoglobulinemia 23 No longer HCC
E15 Nondiabetic hypoglycemic coma 23 No longer HCC
E200 Idiopathic hypoparathyroidism 23 No longer HCC
E208 Other hypoparathyroidism 23 No longer HCC
E209 Hypoparathyroidism, unspecified 23 No longer HCC
E210 Primary hyperparathyroidism 23 No longer HCC

E211 Secondary hyperparathyroidism, not elsewhere classified 23 No longer HCC

E212 Other hyperparathyroidism 23 No longer HCC

E213 Hyperparathyroidism, unspecified 23 No longer HCC
HCC 23 - Other Significant Endocrine and Metabolic Disorders

CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28

E214 Other specified disorders of parathyroid gland 23 No longer HCC

E215 Disorder of parathyroid gland, unspecified 23 No longer HCC

E221 Hyperprolactinemia 23 No longer HCC

E222 Syndrome of inappropriate secretion of antidiuretic hormone 23 No longer HCC

E228 Other hyperfunction of pituitary gland 23 No longer HCC

E229 Hyperfunction of pituitary gland, unspecified 23 No longer HCC

E230 Hypopituitarism 23 No longer HCC

E231 Drug-induced hypopituitarism 23 No longer HCC
E232 Diabetes insipidus 23 No longer HCC

E233 Hypothalamic dysfunction, not elsewhere classified 23 No longer HCC

HCC 23 - Other Significant Endocrine and Metabolic Disorders

CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28

E261 Secondary hyperaldosteronism 23 No longer HCC

E2681 Bartter's syndrome 23 No longer HCC
E2689 Other hyperaldosteronism 23 No longer HCC
E269 Hyperaldosteronism, unspecified 23 No longer HCC
E270 Other adrenocortical overactivity 23 No longer HCC
E272 Addisonian crisis 23 No longer HCC

E273 Drug-induced adrenocortical insufficiency 23 No longer HCC

E2740 Unspecified adrenocortical insufficiency 23 No longer HCC

E2749 Other adrenocortical insufficiency 23 No longer HCC

E275 Adrenomedullary hyperfunction 23 No longer HCC
 HCC 18 - Diabetes with Chronic Complication

➢As discussed earlier, about 80 DM related diagnosis have been dropped in V28
HCC model

Diagnosis Diagnosis Description V24 HCC HCC Description - V24 V28 HCC HCC Description - V28
Type 2 diabetes mellitus with Diabetes with Acute Diabetes with Severe Acute
E11.10 ketoacidosis without coma HCC 17 Complications HCC 36 Complications

Type 2 diabetes mellitus with

diabetic peripheral angiopathy Diabetes with Chronic Diabetes with Chronic
E11.51 without gangrene HCC 18 Complications HCC 37 Complications
Diabetes with Glycemic,
Type 2 diabetes mellitus without Diabetes without Unspecified, or No
E11.9 complications HCC 19 Complication HCC 38 Complications
Diabetes with Glycemic,
Diabetes without Unspecified, or No
Z79.4 Long term (current) use of insulin HCC 19 Complication HCC 38 Complications
 HCC 18 - Diabetes with Chronic Complication

➢Below listed DM codes no longer map to HCC in V28 model.

CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28

Drug or chemical induced diabetes mellitus with hyperosmolarity

E0900 17 No longer HCC
without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
Drug or chemical induced diabetes mellitus with hyperosmolarity with
E0901 17 No longer HCC
coma
Drug or chemical induced diabetes mellitus with ketoacidosis without
E0910 17 No longer HCC
coma
Drug or chemical induced diabetes mellitus with ketoacidosis with
E0911 17 No longer HCC
coma
E0921 Drug or chemical induced diabetes mellitus with diabetic nephropathy 18 No longer HCC
Drug or chemical induced diabetes mellitus with diabetic chronic
E0922 18 No longer HCC
kidney disease
Drug or chemical induced diabetes mellitus with other diabetic kidney
E0929 18 No longer HCC
complication
 HCC 18 - Diabetes with Chronic Complication

➢Below listed DM codes no longer map to HCC in V28 model.

CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28
Drug or chemical induced diabetes mellitus with unspecified diabetic
E09311 18 No longer HCC
retinopathy with macular edema
Drug or chemical induced diabetes mellitus with unspecified diabetic
E09319 18 No longer HCC
retinopathy without macular edema
Drug or chemical induced diabetes mellitus with mild nonproliferative
E093211 18 No longer HCC
diabetic retinopathy with macular edema, right eye
Drug or chemical induced diabetes mellitus with mild nonproliferative
E093212 18 No longer HCC
diabetic retinopathy with macular edema, left eye
Drug or chemical induced diabetes mellitus with mild nonproliferative
E093213 18 No longer HCC
diabetic retinopathy with macular edema, bilateral
Drug or chemical induced diabetes mellitus with mild nonproliferative
E093219 18 No longer HCC
diabetic retinopathy with macular edema, unspecified eye
Drug or chemical induced diabetes mellitus with mild nonproliferative
E093291 18 No longer HCC
diabetic retinopathy without macular edema, right eye
 HCC 18 - Diabetes with Chronic Complication

➢Below listed DM codes no longer map to HCC in V28 model.

CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28
Drug or chemical induced diabetes mellitus with mild non proliferative
E093292 18 No longer HCC
diabetic retinopathy without macular edema, left eye
Drug or chemical induced diabetes mellitus with mild non proliferative
E093293 18 No longer HCC
diabetic retinopathy without macular edema, bilateral
Drug or chemical induced diabetes mellitus with mild non proliferative
E093299 18 No longer HCC
diabetic retinopathy without macular edema, unspecified eye
Drug or chemical induced diabetes mellitus with moderate non
E093311 18 No longer HCC
proliferative diabetic retinopathy with macular edema, right eye
Drug or chemical induced diabetes mellitus with moderate non
E093312 18 No longer HCC
proliferative diabetic retinopathy with macular edema, left eye
Drug or chemical induced diabetes mellitus with moderate non
E093313 18 No longer HCC
proliferative diabetic retinopathy with macular edema, bilateral
Drug or chemical induced diabetes mellitus with moderate non
E093319 18 No longer HCC
proliferative diabetic retinopathy with macular edema, unspecified eye
 HCC 18 - Diabetes with Chronic Complication

➢Below listed DM codes no longer map to HCC in V28 model.

CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28
Drug or chemical induced diabetes mellitus with moderate nonproliferative
E093391 18 No longer HCC
diabetic retinopathy without macular edema, right eye
Drug or chemical induced diabetes mellitus with moderate non proliferative
E093392 18 No longer HCC
diabetic retinopathy without macular edema, left eye
Drug or chemical induced diabetes mellitus with moderate non proliferative
E093393 18 No longer HCC
diabetic retinopathy without macular edema, bilateral
Drug or chemical induced diabetes mellitus with moderate non proliferative
E093399 18 No longer HCC
diabetic retinopathy without macular edema, unspecified eye
Drug or chemical induced diabetes mellitus with severe non proliferative
E093411 18 No longer HCC
diabetic retinopathy with macular edema, right eye
Drug or chemical induced diabetes mellitus with severe non proliferative
E093412 18 No longer HCC
diabetic retinopathy with macular edema, left eye
Drug or chemical induced diabetes mellitus with severe nonproliferative
E093413 18 No longer HCC
diabetic retinopathy with macular edema, bilateral
HCC 40 - Rheumatoid Arthritis and Inflammatory Connective
Tissue Disease
➢ A connective tissue disease is any disease that
has the connective tissues of the body as a
primary target of pathology which are the
structural portions of our body that essentially
hold the cells of the body together
➢ The connective tissues are composed of two
major structural protein molecules: collagen and
elastin
➢ In patients with connective tissue diseases, it is
common for collagen and elastin to become
injured by inflammation
➢ The common symptoms include muscle and
joint pain and stiffness
➢ The diagnostic method includes physical
examination, blood test and X ray examination
HCC 40-Rheumatoid Arthritis and Inflammatory Connective
Tissue Disease
➢Below listed diagnosis are no longer HCC in V28 model
CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28
M320 Drug-induced systemic lupus erythematosus 40 No longer HCC
M342 Systemic sclerosis induced by drug and chemical 40 No longer HCC
M3500 Sjogren syndrome, unspecified 40 No longer HCC
M3501 Sjogren syndrome with keratoconjunctivitis 40 No longer HCC
M3503 Sjogren syndrome with myopathy 40 No longer HCC

M3504 Sjogren syndrome with tubulo-interstitial nephropathy 40 No longer HCC

M3505 Sjogren syndrome with inflammatory arthritis 40 No longer HCC

Sjogren syndrome with peripheral nervous system
M3506 40 No longer HCC
involvement

M3507 Sjogren syndrome with central nervous system involvement 40 No longer HCC

M3508 Sjogren syndrome with gastrointestinal involvement 40 No longer HCC

HCC 40 - Rheumatoid Arthritis and Inflammatory Connective
Tissue Disease
CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28
M4600 Spinal enthesopathy, site unspecified 40 No longer HCC

M4601 Spinal enthesopathy, occipito-atlanto-axial region 40 No longer HCC

M4602 Spinal enthesopathy, cervical region 40 No longer HCC

M4603 Spinal enthesopathy, cervicothoracic region 40 No longer HCC

M4604 Spinal enthesopathy, thoracic region 40 No longer HCC

M4605 Spinal enthesopathy, thoracolumbar region 40 No longer HCC

M4606 Spinal enthesopathy, lumbar region 40 No longer HCC

M4607 Spinal enthesopathy, lumbosacral region 40 No longer HCC

M4608 Spinal enthesopathy, sacral and sacrococcygeal region 40 No longer HCC

HCC 40 - Rheumatoid Arthritis and Inflammatory Connective
Tissue Disease

Rheumatoid ➢ Only the listed below diagnosis codes have been added
Arthritis and under HCC 93 in version 28 mapping.
Inflammatory ➢ No other changes have been implemented in HCC 40 to
HCC 40

Connective HCC 93 transition

Tissue Disease
Diagnosis Description CMS-HCC
Code Model
Rheumatoid Category
V28
Arthritis and
HCC 93

other specified D8686 Sarcoid arthropathy 93

Inflammatory D8687 Sarcoid myositis 93
Rheumatic G7241 Inclusion body myositis [IBM] 93
Disorders
HCC 59 - Major Depressive, Bipolar, and Paranoid Disorders
➢ HCC 59 includes Major Depressive disorder, Bipolar disorder and paranoid disorders, suicide
attempts diagnosis code
➢ HCC 59 is the most captured HCC in retrospective coding whereas 424 codes have been removed
from Version 28 HCC model
➢ V28 has altered HCC 59 to HCC 155 Major Depression, Moderate or Severe, without Psychosis
➢ As the HCC category name indicates Major depression, single episode mild is no longer mapped to
HCC
HCC 59 - Major Depressive, Bipolar, and Paranoid Disorders

CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28
F304 Manic episode in full remission 59 No longer HCC
Bipolar disorder, currently in remission, most recent episode
F3170 59 No longer HCC
unspecified
F3172 Bipolar disorder, in full remission, most recent episode hypomanic 59 No longer HCC

F3174 Bipolar disorder, in full remission, most recent episode manic 59 No longer HCC

F3176 Bipolar disorder, in full remission, most recent episode depressed 59 No longer HCC

F3178 Bipolar disorder, in full remission, most recent episode mixed 59 No longer HCC

F320 Major depressive disorder, single episode, mild 59 No longer HCC

F324 Major depressive disorder, single episode, in partial remission 59 No longer HCC

F325 Major depressive disorder, single episode, in full remission 59 No longer HCC
HCC 59 - Major Depressive, Bipolar, and Paranoid Disorders
CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28

T550X2S Toxic effect of soaps, intentional self-harm, sequela 59 No longer HCC

T551X2S Toxic effect of detergents, intentional self-harm, sequela 59 No longer HCC

T560X2S Toxic effect of lead and its compounds, intentional self-harm, sequela 59 No longer HCC

Toxic effect of mercury and its compounds, intentional self-harm,

T561X2S 59 No longer HCC
sequela
Toxic effect of chromium and its compounds, intentional self-harm,
T562X2S 59 No longer HCC
sequela
Toxic effect of cadmium and its compounds, intentional self-harm,
T563X2S 59 No longer HCC
sequela

T564X2S Toxic effect of copper and its compounds, intentional self-harm, sequela 59 No longer HCC

T565X2S Toxic effect of zinc and its compounds, intentional self-harm, sequela 59 No longer HCC
HCC 59 - Major Depressive, Bipolar, and Paranoid Disorders

F34.9 is no longer HCC in Version 28

HCC 72 - Spinal Cord Disorders/Injuries

➢ HCC 72 includes Spinal cord disorders such as

infection in spinal cord, Inflammatory diseases of
spinal cord, congenital malformation of spinal cord
structures and injury related to various levels of
spine

➢ Version 28 of HCC Mapping fissured HCC 72 to

three different HCC categories such as HCC 182,
HCC 190 and HCC 200
 HCC 72 - Spinal Cord Disorders/Injuries

• Spinal cord disorder/Injuries

HCC 182

• Amyotrophic Lateral Sclerosis and Other Motor Neuron Disease, Spinal Muscular
Atrophy
HCC 190

• Friedreich and Other Hereditary Ataxias; Huntington Disease

HCC 200
 HCC 72 - Spinal Cord Disorders/Injuries

• B00.82-Herpes simplex myelitis

• S14.0XXA-Concussion and edema of cervical spinal cord, initial encounter
HCC 182

• G12.0-Infantile spinal muscular atrophy, type I [Werdnig-Hoffman]

• G12.0-G12.9 (Only 4 diagnosis codes have been classified under HCC 190)
HCC 190

• G11.3-Cerebellar ataxia with defective DNA repair

HCC 200 • G11.4-Hereditary spastic paraplegia
 HCC 72 - Spinal Cord Disorders/Injuries

CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28

S140XXS Concussion and edema of cervical spinal cord, sequela 72 No longer HCC
S14101S Unspecified injury at C1 level of cervical spinal cord, sequela 72 No longer HCC
S14102S Unspecified injury at C2 level of cervical spinal cord, sequela 72 No longer HCC
S14103S Unspecified injury at C3 level of cervical spinal cord, sequela 72 No longer HCC
S14104S Unspecified injury at C4 level of cervical spinal cord, sequela 72 No longer HCC
S14105S Unspecified injury at C5 level of cervical spinal cord, sequela 72 No longer HCC
S14106S Unspecified injury at C6 level of cervical spinal cord, sequela 72 No longer HCC
S14107S Unspecified injury at C7 level of cervical spinal cord, sequela 72 No longer HCC
S14108S Unspecified injury at C8 level of cervical spinal cord, sequela 72 No longer HCC
 HCC 108 - Vascular disease

➢ Vascular disease is a process that affects the blood vessels

of the body. This condition increases the risk of many
HCC different health problems that occur as a result of blood flow
blockage or insufficient blood flow
94
➢ It may lead to serious problems due to insufficient blood flow
and/or blood clots

HCC ➢ Effects of vascular disease include Leg ischemia and

gangrene; Deep vein thrombosis (DVT) in the arm or leg;
108 Pulmonary embolus (PE); Kidney failure; Stroke; Heart
HCC HCC attack, Intestinal ischemia, mesenteric ischemia
264 267 ➢ V24 model categorized vascular disease under HCC 108; but
V28 has fissured HCC 108 to 3 categories as shown: HCC
94; HCC 264; HCC 267
 HCC 108 - Vascular disease

HCC 94

Systemic Lupus Erythematosus and Other Specified

Systemic Connective Tissue Disorders

HCC 264

Vascular Disease with Complications

HCC 267

Deep Vein Thrombosis and Pulmonary Embolism

 HCC 108 - Vascular disease

Systemic Lupus Erythematosus and Other Specified Systemic Connective Tissue Disorders (HCC 94):

➢ Necrotizing vasculopathies (Earlier under HCC 108)

refer to inflammations of the blood vessels that
damage the vascular tissue, often as a result of an
autoimmune response have been categorized under
HCC 94.
➢ Treatment includes the use of drugs to suppress the
immune system such as cyclophosphamide, and
steroids such as prednisone to control inflammation.
 HCC 108 - Vascular disease
Systemic Lupus Erythematosus and Other Specified Systemic Connective Tissue Disorders (HCC 94):

CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28

Other specified necrotizing

M318 108 94
vasculopathies
Necrotizing vasculopathy,
M319 108 94
unspecified
 HCC 108 - Vascular disease
Vascular disease with complications (HCC 264):

➢ Vascular diseases with complications are categorized to HCC 264 and a few diagnosis are listed below

CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28
I70221 Atherosclerosis of native arteries of extremities with rest pain, right leg 108 264

I70222 Atherosclerosis of native arteries of extremities with rest pain, left leg 108 264
Atherosclerosis of native arteries of extremities with rest pain, bilateral
I70223 108 264
legs
Atherosclerosis of native arteries of extremities with rest pain, other
I70228 108 264
extremity
Atherosclerosis of native arteries of extremities with rest pain,
I70229 108 264
unspecified extremity
Atherosclerosis of unspecified type of bypass graft(s) of the
I70321 108 264
extremities with rest pain, right leg
Atherosclerosis of unspecified type of bypass graft(s) of the
I70322 108 264
extremities with rest pain, left leg
 HCC 108 - Vascular disease
➢ Below are few list of diagnosis codes which is no longer HCC in version 28.

CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28
I701 Atherosclerosis of renal artery 108 No longer HCC
I70201 Unspecified atherosclerosis of native arteries of extremities, right leg 108 No longer HCC
I70202 Unspecified atherosclerosis of native arteries of extremities, left leg 108 No longer HCC
I70203 Unspecified atherosclerosis of native arteries of extremities, bilateral legs 108 No longer HCC
I70208 Unspecified atherosclerosis of native arteries of extremities, other extremity 108 No longer HCC
I70209 Unspecified atherosclerosis of native arteries of extremities, unspecified extremity 108 No longer HCC
Atherosclerosis of native arteries of extremities with intermittent claudication, right
I70211 108 No longer HCC
leg

I70212 Atherosclerosis of native arteries of extremities with intermittent claudication, left leg 108 No longer HCC
 HCC 108 - Vascular disease
CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28
I712 Thoracic aortic aneurysm, without rupture 108 No longer HCC
I7120 Thoracic aortic aneurysm, without rupture, unspecified 108 No longer HCC
I7121 Aneurysm of the ascending aorta, without rupture 108 No longer HCC
I7122 Aneurysm of the aortic arch, without rupture 108 No longer HCC
K551 Chronic vascular disorders of intestine 108 No longer HCC
K558 Other vascular disorders of intestine 108 No longer HCC
K559 Vascular disorder of intestine, unspecified 108 No longer HCC

➢ Vascular disease with no complications have been removed HCC category In V28 model. Hence, look for
possible complication to determine the accurate HCC category.

➢ Claudication is pain in legs due to little blood flow and is not categorized as vascular disease complication.
 HCC 167 - Major head injury

➢ Most of the sequalae head injury diagnosis were removed from V28 HCC Mapping as seen
below
CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28
S020XXS Fracture of vault of skull, sequela 167 No longer HCC

S02101S Fracture of base of skull, right side, sequela 167 No longer HCC

S02102S Fracture of base of skull, left side, sequela 167 No longer HCC

S02109S Fracture of base of skull, unspecified side, sequela 167 No longer HCC
Type I occipital condyle fracture, unspecified side,
S02110S 167 No longer HCC
sequela
Type II occipital condyle fracture, unspecified side,
S02111S 167 No longer HCC
sequela
Type III occipital condyle fracture, unspecified side,
S02112S 167 No longer HCC
sequela
 HCC 167 - Major head injury

➢ Version 28 fissures Major head injury into two categories as HCC 398 and HCC 399 based on
the loss of consciousness(LOC) experienced by the patient

➢ The LOC can be directly attested by the provider in assessment, or it can be correlated from
active headers of the visit
HCC 85 - Congestive Heart Failure

HCC
222

HCC HCC
223 226

HCC
227
 HCC 85 - Congestive Heart Failure

• End-Stage Heart Failure

HCC 222 • End stage heart failure-I50.84
HCC
222
• Heart Failure with Heart Assist Device/Artificial Heart
HCC 223 • Breakdown (mechanical) HCC
of artificial heart,
222 HCC initial encounter-T82.512A
226
• Acute on Chronic Heart Failure
HCC 224 • Acute on chronic diastolic (congestive) heart failure-I50.33
HCC
227
 HCC 85 - Congestive Heart Failure

• Acute Heart Failure (Excludes Acute on chronic)

HCC 225 • Acute diastolic (congestive)
HCC heart failure-I50.31
222
• Heart Failure, Except End-stage and Acute
HCC 226 • Chronic diastolic (congestive) heart failure-I50.32
HCC 222 HCC
226
• Cardiomyopathy/Myocarditis
HCC 227 • Dilated cardiomyopathy-I42.0
HCC
227
 Extended HCC categories of V28

➢ Approximately 2294 codes have been deleted and 268 codes have been added
➢ Version 28 comprises of re-numbering and changing HCC category description
➢ Changes to the HCC coefficient values (risk scores that map to each HCC category)
➢ Diagnosis like Benign carcinoid tumor, retinal vein occlusion, severe persistent asthma and several
newborn, congenital codes have been mapped under various HCC categories in Version 28 model
➢ The calculation of RAF score during the transition phase requires the usage of both V24 and V28
models
 HCC 22 - Bladder, Colorectal, and Other Cancers
➢ Carcinoid tumors, which are one subset of tumors called neuroendocrine tumors, usually begin in the
digestive tract (stomach, appendix, small intestine, colon, rectum) or in the lungs
➢ Carcinoid tumors are cancerous but have been called cancer in slow motion
➢ (D3A.00- to D3A.09-) and D3A.8 are newly added benign carcinoid tumor in HCC 22
➢ Below listed medical Condition are more likely to develop carcinoid tumor
▪ Atrophic gastritis, a chronic inflammatory disease in your GI tract
▪ Familial small bowel neuroendocrine tumor, which causes tumors in your small intestine
▪ Multiple endocrine neoplasia (MEN) type I, which causes tumors in the glands of your endocrine
system
▪ Neurofibromatosis type 1 (NF1).
▪ Tuberous sclerosis complex (TSC).
▪ Von Hippel Lindau (VHL) disease.
➢ Diagnostic tests include :
▪ Colonoscopy
▪ Upper endoscopy
▪ Biochemical tests which measures hormones/chemicals from Urine or Blood sample.
▪ Other imaging tests include CT scan, PET scan and MRI.
HCC 50 - Amyloidosis, Porphyria, and Other Specified Metabolic
Disorders
➢ Amyloidosis is a rare disease of abnormal amyloid deposits in the body. It can affect the heart, brain, kidneys,
spleen and other organs
➢ Porphyria is a group of liver disorders in which substances called porphyrins build up in the body, adversely
affecting the skin or nervous system
➢ Wilson disease is a genetic disorder causing excessive copper accumulation in the liver, brain and other organs
 HCC 65 - Chronic Hepatitis

➢ Chronic Hepatitis is a well-known HCC from Version 24. The category has been renumbered
and certain new diagnosis codes have been recently added under HCC 65 in version 28
➢ In chronic hepatitis, liver inflammation continues for at least six months. This condition may be
mild, causing relatively little damage, or more serious, causing many liver cells to be destroyed
➢ Harvoni, Sovaldi, Ribavirin, Sofosbuvir are clinically approved drugs that treat Chronic hepatitis.
➢ The listed diagnosis codes are newly added codes under HCC 65 according to V28 HCC model
 HCC 65 - Chronic Hepatitis

CMS HCC
Diagnosis
Description Model V28
Code
category

K7010 Alcoholic hepatitis without ascites

65
K7011 Alcoholic hepatitis with ascites
65
K713 Toxic liver disease with chronic persistent hepatitis
65
K714 Toxic liver disease with chronic lobular hepatitis
65
K7150 Toxic liver disease with chronic active hepatitis without ascites
65
K7151 Toxic liver disease with chronic active hepatitis with ascites 65
HCC 68 - Cholangitis and Obstruction of Bile Duct Without
Gallstones

➢ Cholangitis is an inflammation of the bile duct system that

can be caused by a bacterial infection, an autoimmune
condition, or other factors
➢ A biliary duct obstruction is a blockage of the bile ducts that
carry bile from the liver and gallbladder to the small
intestine. It can be caused by gallstones, inflammation,
trauma, tumors, or other factors
➢ Diagnostic tests include cholangiography, Ultrasound, Fibro
scan, MRI etc
➢ Treatment includes ERCP, cholecystectomy, bile duct
resection , Biliary bypass
 HCC 68 - Cholangitis and Obstruction of Bile Duct Without
Gallstones

CMS-HCC
Model
➢ Here are diagnosis codes newly added Diagnosis Category
under HCC 68 according to V28 HCC Code Description V28
K8301 Primary sclerosing cholangitis 68
model
K8309 Other cholangitis 68
➢ Only five diagnosis codes have been
K831 Obstruction of bile duct 68
added as New HCC mappings in
Q442 Atresia of bile ducts 68
category 68 under V28 model Congenital stenosis and stricture of
Q443 bile ducts 68
 HCC 78 - Intestinal Obstruction/Perforation

➢ HCC 33 is converted to HCC 78 and the category

description is not changed
➢ It remains as Intestinal Obstruction/Perforation and
the category description explains it would be an
inpatient diagnosis and can be rarely encountered
in outpatient setting
➢ All the codes which remained in HCC 33 receives
payment is Version 28 as well
 HCC 78 - Intestinal Obstruction/Perforation

➢ Below listed newborn and congenital diagnosis codes are newly added diagnosis under version 28 HCC
mapping
Diagnosis Description CMS-HCC
Code Model
Category
V28
P771 Stage 1 necrotizing enterocolitis in newborn 78
P772 Stage 2 necrotizing enterocolitis in newborn 78
P773 Stage 3 necrotizing enterocolitis in newborn 78
P779 Necrotizing enterocolitis in newborn, unspecified 78
P780 Perinatal intestinal perforation 78
Q400 Congenital hypertrophic pyloric stenosis 78
Q410 Congenital absence, atresia and stenosis of duodenum 78
Q411 Congenital absence, atresia and stenosis of jejunum 78
Q412 Congenital absence, atresia and stenosis of ileum 78
HCC 137 - Drug Use Disorder, Moderate/Severe, or Drug Use with Non-
Psychotic Complications

➢ Newly added newborn diagnosis under HCC 137

category are listed below
CMS-HCC
Diagnosis Model
HCC Description

55 HCC Code Category

V28
137 P040
Newborn affected by maternal anesthesia
and analgesia in pregnancy, labor and 137
delivery
Newborn affected by maternal antineoplastic
P0411 137
chemotherapy
Newborn affected by maternal cytotoxic
P0412 137
Drug Use Disorder, drugs
Drug/Alcohol Newborn affected by maternal use of
Moderate/Severe, or P0413 137
Dependence anticonvulsants
Drug Use with Non- P0414 Newborn affected by maternal use of opiates 137
Psychotic Newborn affected by maternal use of
P0415 137
Complications antidepressants
Newborn affected by maternal use of
P0416 137
amphetamines
Newborn affected by maternal use of
P0417 137
sedative-hypnotics
 Perinatal codes in HCC

CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28
➢ HCC 192, 202, 212, 213, 248 has Kernicterus due to
P570 Not an HCC 192
no major changes in the existing isoimmunization
P578 Other specified kernicterus Not an HCC 192
diagnosis codes mapped, instead P579 Kernicterus, unspecified Not an HCC 192
certain perinatal codes have been P910 Neonatal cerebral ischemia Not an HCC 202
Acquired periventricular cysts of
added in Version 28 of HCC model. P911
newborn
Not an HCC 202
P912 Neonatal cerebral leukomalacia Not an HCC 202
P2881 Respiratory arrest of newborn Not an HCC 212
➢ Here are the list of few perinatal P270 Wilson-Mikity syndrome Not an HCC 213
codes which has been added under P271
Bronchopulmonary dysplasia
Not an HCC 213
originating in the perinatal period
HCC 192, 202, 212 etc.
Other chronic respiratory diseases
P278 Not an HCC 213
originating in the perinatal period
Unspecified chronic respiratory
P279 disease originating in the perinatal Not an HCC 213
period
HCC 186 - Major Organ Transplant or Replacement Status

HCC
35
HCC HCC
454 77
HCC
186
HCC HCC
276 62
HCC
221
HCC 186 - Major Organ Transplant or Replacement Status

• Liver Transplant Status/Complications

HCC 62 • Liver transplant rejection-T86.41
HCC
222
• Multiple sclerosis
HCC 77 • Intestinal Transplant Rejection-T86.850
HCC
226
• Heart Transplant Status/Complications
HCC 221 • Heart transplant infection-T86.23
HCC
227
HCC 186 - Major Organ Transplant or Replacement Status

• Inflammatory Bowel Disease

HCC 35 • Pancreas transplant
HCCrejection-Z94.83
222
• Lung Transplant Status/Complications
HCC 276 • Lung transplant failure-T86.810 HCC
226
• Stem Cell, Including Bone Marrow, Transplant
Status/Complications
HCC 454 • Stem cells transplant status-Z94.84
HCC
227
HCC 153 - Personality Disorders; Anorexia/Bulimia Nervosa
➢HCC 153 includes personality disorders which are already a part of Version 24 and also includes eating
disorders like anorexia, Bulimia nervosa as new HCC category in Version 28
➢Anorexia is an eating disorder characterized by an abnormally low body weight, an intense fear of gaining
weight and a distorted perception of weight
➢Symptoms include extreme weight loss, thin appearance, fatigue, insomnia and bluish discoloration of
fingers
➢Treatment includes antidepressants and Counselling regarding healthy diet
HCC 153 - Personality Disorders; Anorexia/Bulimia Nervosa

CMS-HCC CMS-HCC
Diagnosis Model Model
Description
Code Category Category
V24 V28

F5000 Anorexia nervosa, unspecified Not an HCC 153

F5001 Anorexia nervosa, restricting type Not an HCC 153

Anorexia nervosa, binge eating/purging
F5002 Not an HCC 153
type
F502 Bulimia nervosa Not an HCC 153
F600 Paranoid personality disorder 60 153
F601 Schizoid personality disorder 60 153
F602 Antisocial personality disorder 60 153
F603 Borderline personality disorder 60 153
F604 Histrionic personality disorder 60 153
 HCC 279 - Severe Persistent Asthma

➢ HCC 279 is a new HCC category extended in version 28

➢ As the HCC descriptor conveys, only severe persistent asthma is categorized for payment under
HCC
➢ Testing lung function includes spirometry, peak flow, or methacholine challenge
➢ Treatment includes Inhaled corticosteroids

CMS-HCC
Model
Diagnosis Category
Code Description V28
J4550 Severe persistent
asthma, uncomplicated 279
J4551 Severe persistent asthma
with (acute) exacerbation
279
J4552 Severe persistent asthma
with status asthmaticus
279
HCC 298 - Severe Diabetic Eye Disease, Retinal Vein Occlusion,
and Vitreous Hemorrhage

a. Diabetic non proliferative retinopathy b. Retinal vein occlusion c. Vitreous hemorrhage

HCC 298 - Severe Diabetic Eye Disease, Retinal Vein Occlusion,
and Vitreous Hemorrhage
NPDR:
➢NPDR is a condition in which lesions in the retina are confined to the retina and include
microaneurysms, small dot and blot hemorrhages, splinter hemorrhages, and intraretinal
microvascular abnormalities (IRMA)
➢The severity of these lesions determines if the NPDR is mild, moderate, or severe
➢Patient with DM complicated moderate non proliferative diabetic retinopathy with macular
edema (accumulation of fluid in the macula) may experience pain in eyes, blurred vision,
diplopia (double vision), retinal detachment, headache, cataract, glaucoma, dizziness,
and even blindness in severe cases; general symptoms, include increased urinary
frequency and thirst, extreme hunger, fatigue, weight loss, and frequent infections
HCC 298 - Severe Diabetic Eye Disease, Retinal Vein Occlusion,
and Vitreous Hemorrhage
Retinal Vein Occlusion:
➢When a vein in the retina is blocked (occluded), or when a larger blood vessel presses
down on the vein, it is called a retinal vein occlusion
➢Symptoms include blurry or less vision, noticing floaters in field of vision
➢There are two types of retinal vein occlusion:
✓ CRVO (central retinal vein occlusion). This is when the eye’s main vein is blocked
✓ BRVO (branch retinal vein occlusion). This is when small blood vessels attached to the eye’s main vein
are blocked
HCC 298 - Severe Diabetic Eye Disease, Retinal Vein Occlusion,
and Vitreous Hemorrhage
Vitreous Hemorrhage:
➢A vitreous hemorrhage is bleeding occurring in the fluid of the eye
➢Vitreous hemorrhage is a symptom and not the disease by itself
➢Some causes of vitreous hemorrhage are injury and diabetic retinopathy
➢Treatment will vary depending on the cause and severity of the vitreous hemorrhage.
Regular eye exams and the use of protective eyewear can reduce your chances of
developing a vitreous hemorrhage
HCC 298 - Severe Diabetic Eye Disease, Retinal Vein Occlusion,
and Vitreous Hemorrhage
Diagnostic eye tests include:
• Ophthalmoscopy
• Tonometry
• fundus photography
• optical coherence tomography
• fluorescein or indocyanine green angiography
• B–scan ultrasonography
Diagnostic tests for DM include:
• Glucose tolerance tests
• Plasma glucose levels
• HbA1c levels
• CBC, Urine for albumin, glucose , ketones and anti-insulin antibodies.
 HCC Mapping Excel

➢Download the HCC Mapping excel from www.cms.gov.in

➢It would be available under “ 2024 Initial ICD 10 Mappings.”
 Risk Score Calculation

Step 1: Click on coding tools for HCC calculator.- Search about HCC
calculator
 Risk Score Calculation

Step 2: Click on CMS version of HCC model to derive the Risk adjustment
score
 Risk Score Calculation

Step 3:Fill in all the details to Obtain RAF score

 Risk Score Calculation

Step 4:RAF score obtained as below

Notes: CMS relies on the historical method for calculating the FFS normalization factor, without any
special adjustments; Each year CMS adjust payments to reflect differences in diagnosis coding.
 Sample coding

Assessment and Plan

 Sample coding

Diagnosis 1:Major depressive disorder, recurrent, moderate (F33.1)-

Appropriate MEAT is supported. Continue on Citalopram

Can this Diagnosis be captured in both Version 24 and 28 HCC model?

 Sample coding

Can this Diagnosis be captured in both Version 24 and 28 HCC model?

 Sample coding

Answer:
Diagnosis Major depressive disorder,
recurrent, moderate will receive payment in
both V24 and V28 HCC model.
 Sample coding

Diagnosis 2: Unspecified atherosclerosis of native arteries of extremities,

bilateral legs (I70.203)- Provider has documented lifestyle changes to
manage the atherosclerosis of bilateral extremities.

Can this Diagnosis be captured in both Version 24 and 28 HCC model?

Sample coding
 Sample coding

Answer:
➢ Unspecified atherosclerosis of native extremities,
bilateral legs will receive payment under Version
24 whereas it is not defined HCC diagnosis under
version 28.
➢ Coding guidelines remains same, ie. DM with
atherosclerosis will lead to E11.51 and this is a
HCC diagnosis an categories under HCC 37 as per
Version 28.
 Sample coding

Diagnosis 3:Secondary hyperparathyroidism of renal origin (N25.81). Provider

has documented lifestyle management as appropriate treatment plan.

Can this Diagnosis be captured in both Version 24 and 28 HCC model?

Sample coding
 Sample coding

Answer:
➢ Secondary hyperparathyroidism of renal origin
(N25.81) will receive payment under Version 24
whereas it is not defined HCC diagnosis under
version 28.

➢ N25.81 can be captured in version 24 whereas it

cannot be captured in version 28.
 Summary

➢ CMS proposed changing to V28 starting January 2024 but compromised of phasing in
V28 over three years.
➢ By the end of three years, Version 24 will be no longer useful. Hence transition to
version 28 must be drastically implemented in our projects.

Year V24 V28

2024 67% 33%

2025 33% 67%

2026 0% 100%
 References
➢ Pareto Insights: Medicare Advantage Payment Year 2024 Model Update (v28) (paretointel.com)

➢ HCC coding: V24 versus V28 – CodingIntel

➢ www.imohealth.com

➢ Risk adjustment: A look at version 28 2024 - 3M Inside Angle

➢ How CMS-HCC Version 28 will impact risk adjustment factor (RAF) scores | Wolters Kluwer

➢ CMS-HCC Model Category V28 vs V24: A Comprehensive Analysis (emedlogix.com)

➢ www.cms.gov.in

➢ https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/hierarchical-condition-
category.html