Table 2. Prospective Hierarchical Coexisting Conditions Models, With Incremental Payment Weights1.
| HCC | Label | Example(s) | Hierarchy (Rank) | Percent of Medicare Beneficiaries2 | Incremental Payment | |
|---|---|---|---|---|---|---|
|
| ||||||
| HCC—Diagnosis Only | HCCP—Includes Procedures | |||||
| 1 | High-Cost Infectious Diseases | Septicemia, HIV/AIDS | None | 1.1 | $4,116 | $3,045 |
| 2* | Moderate-Cost Infectious Diseases | Tuberculosis, meningitis | None | 2.1 | — | 1,411 |
| 4 | Metastatic Cancer | — | Neoplasm (1) | 1.3 | 6,298 | 4,332 |
| 5 | High-Cost Cancers | Lung cancer | Neoplasm (2) | 0.9 | 4,226 | 3,457 |
| 6 | Moderate-Cost Cancers | Kidney cancer, brain cancer | Neoplasm (3) | 2.0 | 2,168 | 1,680 |
| 7 | Lower-Cost Cancers | Prostate cancer, breast cancer | Neoplasm (4) | 4.8 | 910 | 576 |
| 8* | Carcinoma in Situ | — | Neoplasm (5) | 0.4 | — | 456 |
| 12 | High-Cost Diabetes | Hypoglycemic coma | Diabetes (1) | 1.5 | 3,939 | 3,871 |
| 13 | Lower-Cost Diabetes | Diabetes without complications | Diabetes (2) | 12.0 | 1,451 | 1,425 |
| 14 | Protein-Calorie Malnutrition | — | None | 0.6 | 3,961 | 2,451 |
| 17 | Liver Disease | Cirrhosis | None | 0.4 | 4,269 | 3,971 |
| 18 | High-Cost Gastrointestinal Disorders | Intestinal obstruction | Gastrointestinal (1) | 2.5 | 2,146 | 1,827 |
| 19* | Moderate-Cost Gastrointestinal Disorders | Ulcer without perforation | Gastrointestinal (2) | 7.8 | — | 751 |
| 21 | Bone Infections | Osteomyelitis | None | 0.6 | 2,111 | 1,770 |
| 22 | Rheumatoid Arthritis and Connective Tissue Disease | Systemic lupus erythematosus | None | 2.6 | 1,516 | 1,442 |
| 24 | Aplastic and Acquired Hemolytic Anemias | — | Hematological (1) | 0.3 | 5,505 | 4,778 |
| 25 | Blood/Immune Disorders | Hemophilia | Hematological (2) | 1.8 | 1,337 | 994 |
| 28 | Drug and Alcohol Dependence/Psychoses | — | Mental (1) | 0.7 | 2,442 | 2,318 |
| 29 | Higher-Cost Mental Disorders | Schizophrenia | Mental (2) | 4.4 | 1,635 | 1,603 |
| 31 | Quadriplegia/Paraplegia | — | Neurological (1) | 0.2 | 5,609 | 4,996 |
| 32 | Higher-Cost Nervous System Disorders | Parkinson's disease, multiple sclerosis | Neurological (2) | 6.3 | 1,556 | 1,436 |
| 34 | Respiratory Arrest | — | Cardio-respiratory arrest (1) | 0.3 | 9,282 | 6,561 |
| 35 | Cardiac Arrest/Shock | — | Cardio-respiratory arrest (2) | 0.3 | 1,759 | 1,271 |
| 36 | Respiratory Failure | — | Cardio-respiratory arrest (3) | 2.5 | 2,797 | 2,237 |
| 37 | Congestive Heart Failure | — | Heart (1) | 9.9 | 3,063 | 2,873 |
| 38 | Heart Arrhythmia | Ventric Tachycardia | Heart (2) | 3.2 | 1,333 | 1,212 |
| 39 | Valvular Heart Disease | Rheumatic Fever/Heart Disease | Heart (3) | 2.4 | 804 | 757 |
| 40 | Coronary Artery Disease | Myocardial infarction, angina pectoris | Heart (3) | 13.7 | 1,049 | 995 |
| 45 | Cerebrovascular Disease | Cerebrovascular accident | None | 8.4 | 1,253 | 1,174 |
| 46 | Vascular Disease | Atherosclerosis, aneurysm | None | 12.1 | 1,114 | 1,015 |
| 48 | Chronic Obstructive Pulmonary Disease | Emphysema, Asthma | Lung (1) | 11.9 | 1,555 | 1,448 |
| 49 | Higher-Cost Pneumonia | Pneumococcal pneumonia | Lung (1a) | 1.1 | 2,943 | 2,673 |
| 50* | Lower-Cost Pneumonia | Unspecified pneumonia | Lung (2a) | 4.4 | — | 1,104 |
| 51* | Pleurisy/Fibrosis of Lungs | Black lung disease | Lung (3) | 1.5 | — | 801 |
| 54 | Renal Failure | — | None | 1.4 | 3,454 | 2,907 |
| 58 | Chronic Ulcer of Skin | — | None | 2.5 | 2,633 | 2,461 |
| 60 | Hip and Vertebral Fractures | — | None | 2.4 | 1,109 | 998 |
| 61 | Higher-Cost Injuries and Poisonings | Intracranial injury, third-degree bums | None | 2.2 | $1,254 | $1,052 |
| 63* | Complications of Medical and Surgical Care | Misadventure to patient in surgery | None | 3.4 | — | 709 |
| 64 | Coma | — | None | 0.3 | 1,694 | 1,361 |
| Procedure-Based HCCs | ||||||
| 67* | Major Organ Transplant | Heart transplant | Transplant (1) | 0.0 | — | 5,142 |
| 68* | Status/History of Major Organ Transplant | — | Transplant (2) | 0.1 | — | 1,156 |
| 70* | Tracheostomy | — | Artificial opening, tracheostomy (1) | 0.1 | — | 24,474 |
| 71* | Gastrostomy | — | Artificial opening (1) | 0.2 | — | 5,022 |
| 72* | Enterostomy | — | Artificial opening (1) | 0.1 | — | 5,119 |
| 73* | Artificial Opening Status/Attention | Attention to gastrostomy | Artificial opening (2) | 0.4 | — | 2,236 |
| 74* | Machine Dependence | Ventilator dependence | Tracheostomy (2) | 1.2 | — | 2,190 |
| 77* | Venous Access Port | — | None | 0.1 | — | 7,139 |
| 78* | Chemotherapy | — | None | 0.8 | — | 4,642 |
| 79* | Dialysis | — | None | 0.0 | — | 16,586 |
| 80* | Major Surgical Amputations | Amputation of leg | None | 0.1 | — | 2,607 |
*
Not included in hierarchical coexisting conditions (HCC) payment model.
1
Payment models also include 12 age and sex cells. Age and sex weight must be added to sum of HCC weights to obtain total payment.
2
Percent of sample in category after application of hierarchical restrictions.
SOURCE (for payment weights): 1992 (expenditures) and 1991 (diagnoses) Medicare claims.