CMS-HCCs
The CMS-HCC data mart implements v24 and v28 versions of the CMS-HCC risk model.
There are many tedious steps to map HCCs and calculate risk scores. Most of the critical information is not easy to use since CMS distributes rate announcements annually in PDFs and mappings in Excel files. Many existing tools, such as the SAS program from CMS, require you to have the patient data preprocessed.
Additionally, the new CMS-HCC model V28 will be phased in over three years, requiring organizations to run both models V24 and V28 to create blended risk scores.
- Payment year 2024 risk scores will be blended using 67% of the risk score calculated from V24 and 33% from V28.
- Payment year 2025 risk scores will be blended using 33% of the risk score calculated from V24 and 67% from V28.
- Beginning in payment year 2026 risk scores will be 100% from V28.
Data Requirements
In order to run the CMS-HCC data mart you need to map the following data elements to the Input Layer. These are the only data elements required.
Eligibility:
- patient_id
- gender
- birth_date
- death_date
- enrollment_start_date
- enrollment_end_date
- original_reason_entitlement_code
- dual_status_code
- medicare_status_code
Medical claim:
- claim_id
- claim_line_number
- claim_type
- patient_id
- claim_start_date
- claim_end_date
- bill_type_code
- hcpcs_code
- diagnosis_code_type
- diagnosis_code_1*
*Up to 25 diagnosis codes are allowable, but only 1 is required.