AMGA Opposes Proposed Medicare Advantage Coding Changes

AMGA has asked CMS not to finalize the coding changes included in the 2024 Medicare Advantage Advance Notice that would revise diagnoses and condition categories in the hierarchical condition categories (HCC) model.

According to AMGA, the proposed changes to the risk adjustment model would adversely impact healthcare providers participating in value-based care contracts.

The agency has proposed transitioning from the IDC-9 coding system to ICD-10. AMGA supported this shift but raised concerns about the proposal to implement a revised HCC model that includes fewer ICD-10-CM codes mapped to an HCC for payment purposes.

CMS has proposed to remove more than 2,000 unique codes from the HCC model that cover a variety of conditions, including depressive disorder, vascular disease, rheumatoid arthritis, and diabetes with chronic conditions.

AMGA’s letter to CMS noted that providers will only have a small timeframe to review these changes. This could impact providers in value-based contracts, as participating in value-based programs already comes with challenges like investing in analytics and hiring care managers. Adding more uncertainty to these programs could discourage participation among providers, the organization said.

Past changes to the risk adjustment model have been phased in, allowing plans and providers to adjust their systems and anticipate potential effects. If the proposals in the Advance Notice are finalized, Medicare Advantage plans must submit bids based on the new model by June 5, 2023, four months after CMS released the proposal.

AMGA urged CMS to extend the timeline for implementing the risk adjustment changes to allow adequate time for providers and plans to consider the effects and provide feedback.

AMGA also voiced concerns about the minimal information CMS has provided to stakeholders and the unclear impact the model changes will have.

Specifically, the proposed changes would make all coefficient values the same for the diabetes group in the HCC model, regardless of complication status. This means diabetes with severe acute complications; diabetes with chronic complications; and diabetes with glycemic, unspecified, or no complications will all have the same weight in the risk score, even though there are significant differences in the care needs for these populations. CMS proposed a similar change for congestive heart failure.

“By proposing to collapse these HCCs into a single risk score, CMS is discounting the importance of risk adjustment in the MA program,” the letter stated. “AMGA members in any value-based care arrangement, MA or otherwise, understand how critical accurate risk adjustment is for any population health-based model.”

AMGA said removing codes from the HCC model that represent conditions common among disadvantaged populations is “in stark contrast with CMS’ commitment to advance health equity throughout our public health system.”

The changes will likely reduce payments to Medicare Advantage plans, impacting provider reimbursement and patient care access.

AMGA suggested that CMS not finalize the proposed changes to the HCC model and instead work with stakeholders to help providers and plans understand the proposal’s effects.

While AMGA opposed the changes to the HCC model, the organization supported CMS’ proposal to align quality measures across Medicare. The Universal Foundation measurement is similar to an AMGA 2018 initiative that created a streamlined set of quality measures to simplify the reporting process and reduce provider burden.

AMGA is not the only provider group that has voiced opposition to the removal of diagnostic codes from the HCC model.

America’s Physician Groups (APG) expressed similar concerns and called on CMS to delay the proposed modifications, explain its rationale for the specific coding changes, and acknowledge that the proposals could hinder health equity and value-based care advancements.

APG also commissioned an ATI Advisory analysis which found that the changes would result in fewer patient visits that count toward risk adjustment. The share of visits contributing to risk adjustment would fall by one-third for patients with psychiatric conditions, 38 percent for those with musculoskeletal conditions, and 69 percent for patients with vascular conditions.