©2015 Cognisight, LLC

CMS HCC Model 22: Premium Year 2016, 2015 Dates of Service

May 6, 2015

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©2015 Cognisight, LLC

Agenda 2

CMS 2016 Final Call Letter Highlights

Disease Interactions

Rx HCCs

PY2015 Blended Risk Score Calculation Example

PY2016 Model 22 Risk Score Calculation Example

Next Steps

Questions

Appendices

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CMS Final Call Letter: 2016 Highlights

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Blended HCC Model will be discontinued

o Two years ago, CMS came out with a new HCC Model (22)

o CMS used a blended model when calculating risk scores for both Payment Years PY2014 and PY2015—a percentage from both the old Model 12 and the new Model 22 were used

o For PY2016, CMS will be only using Model 22 when calculating risk scores

Medicare enrollee prospective health risk assessment

o CMS is still accepting risk adjustments from prospective in-home assessments

o Plans adoption of such practices should provide additional information to support care planning and care coordination in order to improve members health outcomes

Encounter Data as a diagnosis source

o In PY2016, CMS will calculate risk scores by blending and weighting 90% from RAPS files and 10% from EDPS files

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Formula factor changes

o Coding Intensity Adjustment

• Increased to 5.41%

• Negative impact to risk scores

o Normalization Factor

• Increased to 0.992%

• Positive impact to risk scores

Factor Current New Impact

MA Coding Adjustment -5.16% -5.41% Change: Negative

Normalization 2014 (Model 22)

-0.978

-0.992

Change: Positive

ESRD Dialysis 1.004 0.990 Change: Positive

Functioning Graft 1.028 1.042 Change: Negative

CMS Final Call Letter: 2016 Highlights, cont.

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Highlights of changes to Rx HCC model for both stand-alone PDPs and MA-PDs

o Model changes to compliment the proposed changes to the 2016 benefit structure

o Update to the data years used to calibrate the model

o Clinical updates to the hierarchical conditions

o Inclusion of the MA-PD data in the model calibration

o An actuarial adjustment to the RxHCC for Chronic Viral Hepatitis

o Renumbering of RxHCCs

o CMS will be recalibrating the RxHCC model yearly

ICD-9 to ICD-10 transition

o Scheduled to take place on October 1, 2015

o The data collection year for risk scores used for Payment Year 2016 would use diagnoses from the prior calendar year (CY2015)

o CMS will use the following when calculating PY2016 risk scores

• ICD-9 codes from dates of service: January 1, 2015–September 30, 2015

• ICD-10 codes from dates of service: October 1, 2015–December 31, 2015

CMS Final Call Letter: 2016 Highlights, cont.

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Disease Interactions 6

In Model 12, there were six Interaction codes for Community factor status and five Interaction codes for Institutional factor status

o Two of the three Diabetes Disease Interactions were eliminated in Model 22

• DM/CVD & RF/CHF/DM

o Only other eliminated Disease Interaction is COPD/CVD/CAD

In Model 22, there are 6 Interaction codes for Community factor status and 12 Interaction codes for Institutional factor status

o New Disease Interactions include Cancer Immune disorders and Sepsis/Cardio Respiratory Failure under the Community Factor status

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Rx HCCs 7

The RxHCC Normalization Factor for Payment Year 2016 is 0.939

CMS has also added and removed some RxHCCs

o New RxHCCs

• Secondary Cancers of Bone, Lung, Brain, and Other Specified Sites

• Liver Cancer

• Chronic Viral Hepatitis C

o Removed RxHCCs

• Gram-Negative/Staphylococcus Pneumonia and Other Lung Infections

• Chronic Kidney Disease Stage 3

• Chronic Kidney Disease Stage 1, 2, or Unspecified Nephritis

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Risk Score Calculation: PY 2015 Blended Model

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Model 12 Factor Type

Model 12 Factor Code

Model 12 HCC Description

Model 12 Weight

Model 22 Factor Type

Model 22 Factor Code

Model 22 HCC Description

Model 22 Weight

HCC 16

Diabetes with Neurologic or Other Specified Manifestation 0.371 HCC 18

Diabetes with Chronic Complications 0.368

HCC 55

Major Depressive, Bipolar, and Paranoid Disorders 0.36 HCC 58

Major Depressive, Bipolar, and Paranoid Disorders 0.33

HCC 71 Polyneuropathy 0.321

HCC 105 Vascular Disease 0.302 HCC 108 Vascular Disease 0.299

Total 1.354 Total 0.997

Normalization Factor .992

Normalization Factor .978

Normalized Risk Score 1.365

Normalized Risk Score 1.019

67% of Normalized Risk Score 0.914

33% of Normalized Risk Score 0.336

Total 2015 HCC Based Risk Score

1.251

In PY2015 CMS used a blended

model when calculating risk

scores

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9

Model 22 Factor Type

Model 22 Factor Code

Model 22 HCC Description

Model 22 Weight

HCC 18 Diabetes with Chronic Complications 0.368

HCC 58 Major Depressive, Bipolar, and Paranoid Disorders 0.33

HCC 108 Vascular Disease 0.299

Total Weight 0.997

Normalization Factor .992

Normalized Risk Score 1.005

Note new normalization

factor for PY2016

Only Model 22 will be used in PY2016 when

calculating risk scores

Risk Score Calculation: PY 2016 Model 22

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Next Steps 10

When preparing PY2016 Bid Rates, please take Model 22 changes into consideration

When coding for 2015 encounters, remember to code to the highest specificity using only Model 22 diagnoses

Work with your providers—MA requires all diagnoses that affect treatment in the review year be submitted once within each calendar year

o Especially important when there is a condition that may not necessarily be treated actively, however the condition exists and does impact the treatment planning of other conditions

Make sure providers are prepared come October 1, 2015 to document according to ICD-10 guidelines

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Questions 11

For questions or more information, please contact:

Jane Brownyard jbrownyard@cognisight.com 585.662.4285

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Appendix: What No Longer Counts in Model 22

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131 ICD-9 codes that no longer map to an HCC in Model 22; the most common diagnoses include

o CKD (HCC 131)Chronic Kidney Disease Stage 1-3 along with unspecified CKD and Nephritis (HCC 132)

• Only CKD Stage 4 (new HCC 135) and Stage 5 (new HCC 136) will be included in the new model

• GFRs are the best way to capture CKD diagnoses and depending on the result may qualify for staging

o Diabetes (HCC 15 & 16)

• The corresponding ICD-9 codes for these HCCs now fall under HCC 18 in Model 22

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o Polyneuropathy (HCC 71) Peripheral Neuropathy

• Toxic Neuropathy (complications of diseases causing the Neuropathy) (new HCC 75) is carried over and remains in the new Model

o Old MI (HCC 83), Asphyxia and Hypoxia (HCC 79)

• Some of the costs associated with these however will be captured by the heart and lung HCCs

o Skin Ulcer (HCC 148)

• Not all skin ulcers are included in the new HCC Model

Stages 1 and 2 do not map to an HCC

Stage 3, 4, and “unstageable” do map to an HCC in Model 22 (new HCC’s 157 or 158)

Appendix: What No Longer Counts in Model 22, cont.

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o Pancreatic Disease (HCC 32)

• Chronic Pancreatitis (HCC 34) is the only Pancreatic disease that maps to an HCC in Model 22

• All of the Acute Pancreatic diagnoses were eliminated

o Celiac Disease (HCC 32)

• Felt to be strongly treated by a person’s diet therefore CMS eliminated this diagnosis from the new Model 22

o Major Complications of Medical Care & Trauma (HCC 164)

• The only ICD-9s in this category that map to an HCC in Model 22 are complications of specified device or graft (HCC 176)

Appendix: What No Longer Counts in Model 22, cont.

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Appendix: What is New in Model 22

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226 new ICD-9 codes that map to an HCC in Model 22; the most common diagnoses include

o SIRS

• Systemic Inflammatory Response Syndrome/Shock along with Sepsis and Severe Sepsis

o Diabetes

• CMS has regrouped Diabetes into 3 categories

Diabetes with Acute Complications (HCC 17)

Diabetes with Chronic Complications (HCC 18)

Diabetes without Complications (HCC 19)

• Code the specific manifestation and remember all of the ICD-9 codes that mapped to HCC 15 and HCC 16, now map to HCC 18 in Model 22

o Morbid Obesity

• The diagnoses that fall under this category include staged ICD-9 codes for Body Mass Index of 40 and over

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o Endocrine and Metabolic Disorders (HCC 23)

• New HCC that includes 80 ICD-9 codes

• Many Metabolic and Immunity Disorders are now included in this new HCC

o Coagulation Defects and Other Specified Hematological Disorders (HCC 48)

• Includes a large number (48) of ICD-9 codes

Many of the ICD-9 codes in this HCC are more specific to blood clotting diagnoses

o Fibrosis of Lung and Other Chronic Lung Disorders (HCC 112)

• Diagnoses that fall under this category include some ICD-9 codes that are specific to environmental lung disorders, such as Asbestosis

Appendix: What is New in Model 22, cont.