For those who have not had a chance to see the 2012 Advance Notice, released by CMS on Feb 18, 2011, there is guidance that CMS does not intend to change the standard HCC model as they had previously announced.  This means that for the non-ESRD models, i.e. the regular Community model, the same HCCs and hierarchy logic will be used for Dates of Service 2011 and 2012 payment.

It appears that the ESRD model will incorporate the new HCCs.  See the Advance Notice for more details.  PDF below.

Advance2012

From yesterday’s CMS April 5, 2011 Announcement, pg. 2:

“Part C Risk Adjustment Model. Based on our interpretation of Congressional intent regarding changes in Part C payment methodology, CMS will not implement the new CMS-HCC and CMS-HCC ESRD dialysis risk adjustment models or the recalibrated frailty factors in 2011. CMS will implement these new models in 2012. To reference the factors in the CMS-HCC risk adjustment model that will be used in 2011, see the 2009 Rate Announcement (published in April 2008). To reference the factors in the CMS-HCC ESRD risk adjustment model that will be used in 2011, see the 2008 Rate Announcement (published in April 2007).”

Link to 2011 Announcement:

http://www.cms.gov/MedicareAdvtgSpecRateStats/AD/list.asp#TopOfPage

I am hearing from several of my readers that the 2011 HCC model codes will implemented starting payment year 2011.  This means that the new code crosswalk (to be finalized April 5th by CMS) will be implemented during the following dates of service windows.  The January 2011 preliminary payment rates will be set by the July, 2009 to June, 2010 12 month dates of service window using the new codes.  The July 2011 payment rates will be set by dates of service in CY2010 using the new codes.

I did a quick comparison of the ICD9s in the current  2010 Payment Year HCC-ICD9 crosswalk to the ICD9s mapped to the preliminary release of the 2011 CMS and found about 250 “newly added” ICD-9 codes that are not in previous models.  Again, this is a prelim release, so treat this file as an FYI that may change.  On tab 2 of the excel are the 100 or so ICD9s slated for deletion for PY2011.  Say goodbye to everyone’s favorite “412 Old Myocardial Infarction”.

2011_HCC_changed_ICD9s(PRELIM) XLS (excel)

Been getting lots of questions lately on which ICD-9 code sets are valid for a particular payment year.  CMS issued guidance on this in their 2009 Advance Notice.

“Starting with payment year 2009, RAPS will only accept valid ICD-9-CM codes for two fiscal years — the fiscal year that begins prior to the payment year and the fiscal year that begins during the payment year — for the CMS-HCC, ESRD, and RxHCC risk adjustment models. For example, for diagnoses codes to be used in 2009 final payment, i.e., for diagnoses from service dates between January 1, 2008 and December 31, 2008, RAPS will only accept codes that are valid for Fiscal Year 2008 and Fiscal Year 2009. (Please note that for the initial risk score run for payment year 2009, CMS will use valid diagnosis codes from FY 2007 and FY 2008 — services dates between July 1, 2007 and June 30, 2008.)”

Advance2009 PDF

Wow, after looking at the 2011 Advance Notice and the prelim 3,090 ICD-9 codes in the 2011 HCC model it is apparent that there are several new HCCs for 2011.  The diabetes group is curtailed from 5 HCCs down to 3.  Dementia HCCs were added.  Pressure Ulcer HCCs (4 of them) were added.

Here are some prelim files for your information – final 2011 model to be finalized in April.

CMS-HCC Model 2011 (PDF – shows HCC revisions)

2011_HCC_ICD9 (XLS – shows 3090 ICD9s mapped to HCC, second tab is the 87 HCCs in the 2011 model- I created this file by crosswalking the 3,090 ICD9s in the prelim model to their English descriptions for 2010 ICD-9 codes.  The second tab is an excel I extracted from the 2011 Advance Notice pdf.

As you have heard, the CMS-HCC Model will change slightly in 2011 with basically some re-organization of ICD-9s into different categories.

Here is a link to the first draft of the codes for 2011.  The final version is expected April, 2010.  This link is to just a numeric crosswalk, I will try to compile a complete file in English in the next few days.

Here are some files showing the 2010 HCC and RxHCC codes:
The truncated codes are indicated by an “*” and are not valid for payment

Original File from CMS – 2010 Model xls

File showing 2009 and 2010 Codes only xlsx

File showing just new ICD9 codes in HCC model for 2010 xls

Don’t forget that the risk scores reported on the MMR have already been adjusted  by the Fee For Service normalization rate, which for payment year 2009 for the standard aged/disabled model is 1.030. The FFS  normalization factor has been applied directly to risk scores instead of the county ratebook since 2007.  So, divide any score you get from manually calculating a patient’s risk score by the FFS 1.030 normalization factor.

The HCC codes/categories in the CMS-HCC 70 Model will stay the same when the new 2010 ICD-9 codes roll out in about a month on October 1st. Looking at the new codes, I only see a handful of new ones that CMS might add to the HCC-ICD9 crosswalk, possibly Merkel cell carcinoma and some new chronic deep vein thrombosis codes. CMS typically publishes a spreadsheet of the new crosswalk during the first week of October and I will post it on the blog when available.

The risk factor values, i.e. the score that each HCC is worth, are not expected to be recalibrated until the 2011 payment year, so they should be the same for 2010 as they were for 2009.