112
diagnosis could be used in cases of chest pain that do not require further treatment, and also
when the diagnosis does not affect the care, treatment or management of the beneficiary.
Additionally, HCC 88 included ICD-10 codes for other or unspecified forms of angina pectoris,
including with atherosclerosis. Independent studies have found that incidental detection of
atherosclerosis through CT scans is “relatively prevalent and carr[ies] high risk for asymptomatic
coronary disease.” For example, in a study of 1,494 clinically healthy adults without a history of
CVD, 68% of those who underwent abdominal CT had atherosclerotic lesions with stenosis in
the aorta or its major branches. Thus, there is a likelihood that atherosclerosis is being coded
based on radiology reports for cases that are asymptomatic.
32
This rationale was also applied to
the ICD-10 diagnosis codes previously included for payment in HCC 108 in the 2020 CMS-HCC
model. Arterial Atherosclerosis with intermittent claudication may not be a good predictor of
medical expenditure because evidence suggests that patients with intermittent claudication often
do not require treatment.
33
In response to a comment suggesting that variation in coding between MA and FFS must be
addressed through a model calibrated with MA encounter data, CMS agrees that an MA coding
pattern difference adjustment would no longer need to be applied to the MA risk scores if the
risk adjustment model were calibrated with MA data. While CMS disagrees with commenters
that changes to the 2024 CMS-HCC model based on Principle 10 are duplicative of the coding
intensity adjustment, and disagrees that CMS does not have the authority to make changes to the
risk adjustment model to account for variability in diagnosis codes submitted, CMS agrees that
the statute supports calibrating a model using MA data submitted on encounter data records.
CMS will engage with stakeholders when we move forward with developing such a model.
CMS-HCC Risk Adjustment Model for PACE organizations for CY 2024
Comment: Several commenters opposed CMS’ proposal to use the 2017 CMS-HCC risk
adjustment model for payment to PACE organizations for CY 2024. These commenters urged
that, for CY 2024, CMS transition PACE organizations to the CMS-HCC risk adjustment model
that is currently being used for MA payment (the 2020 CMS-HCC risk adjustment model). These
commenters are concerned that the 2017 CMS-HCC risk adjustment model excludes several
chronic conditions, especially dementia, which is prevalent in the PACE population.
Commenters also pointed to pressure ulcers (HCC 159), moderate chronic kidney disease (HCC
138), and several mental health and substance use disorder HCCs as condition categories that
they believe are critically important for accurate risk adjustment for PACE organizations.
Commenters believe that the frailty adjustment is inadequate to capture the risk of their
32
Suh, B., Song, Y. S., Shin, D. W., Lim, J., Kim, H., Min, S. H., ... & Cho, B. (2018). Incidentally detected atherosclerosis in
the abdominal aorta or its major branches on computed tomography is highly associated with coronary heart disease in
asymptomatic adults. Journal of cardiovascular computed tomography, 12(4), 305-311.
33
Cassar K. (2006). Intermittent claudication. BMJ (Clinical research ed.), 333(7576), 1002–1005.
https://doi.org/10.1136/bmj.39001.562813.DE