In 2024 a depression diagnosis became a narrower payment category, on purpose
CMS's 2024 risk model split the old Major Depressive, Bipolar, and Paranoid Disorders category into narrower ones, stating that diagnoses subject to discretionary coding should not raise cost predictions. Twenty percent fewer codes pay.
We have not finished checking this source. No judgement either way. how we score evidence
Caveat on this rating: The report describes the reclassification and its rationale; it does not quantify the payment effect of moving depression from HCC 59 to HCC 155, and neither does this row.
Significant findings
Medicare Advantage plans are paid more for enrollees with more diagnoses, so a recorded diagnosis has a price. CMS's December 2024 report to Congress on risk adjustment explains what it changed and why. The 2024 model "classifies the approximately 74,000 ICD-10-CM codes into 266 HCCs, 115 of which are included for payment", with "approximately 20 percent fewer ICD-10-CM codes that are mapped to payment HCCs than the 2020 CMS-HCC model." "As part of the clinical reclassification, CMS did not include certain codes in the payment model where there is wider variation in diagnosing and coding."
The principle is stated as Principle 10: "Discretionary diagnostic categories should be excluded from payment models. Diagnoses that are particularly subject to intentional or unintentional discretionary coding variation or inappropriate coding by health plans/providers, or that are not clinically or empirically credible as cost predictors, should not increase cost predictions."
The mental-health table shows the move: the 2020 model's "HCC 59 Major Depressive, Bipolar, and Paranoid Disorders" became, in the 2024 model, "HCC 154 Bipolar Disorders without Psychosis" and "HCC 155 Major Depression, Moderate or Severe, without Psychosis."
Worth asking
Read that with the screening rows in mind. A positive PHQ-9 that turns into a diagnosis code used to land in a broad category with a payment weight; now it lands in a narrower one that requires "Moderate or Severe." The regulator's own stated reason is discretionary coding. Whether your diagnosis is in your record because you have it, or because it was worth recording, is not a question the model can answer.
Source
Report to Congress: Risk Adjustment in Medicare Advantage, December 2024 — Centers for Medicare & Medicaid Services (2024)
How this was scored
- Study design
- not recorded
- Funding
- not recorded
- Published in
- not recorded
- Sample size
- not recorded
- Preregistered
- not recorded
- Conflicts disclosed
- not recorded
- Independent of proponent
- not recorded
- Retracted
- No
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Published September 17, 2026.
Questions
How strong is the evidence behind this?
veisund rates this source "not yet assessed". We have not finished checking this source. No judgement either way. One caveat travels with that badge: The report describes the reclassification and its rationale; it does not quantify the payment effect of moving depression from HCC 59 to HCC 155, and neither does this row. The score is calculated from recorded facts about the source — study design, funding, publication venue, sample size, preregistration — not typed in by an editor.
What is the source for this?
Report to Congress: Risk Adjustment in Medicare Advantage, December 2024 — Centers for Medicare & Medicaid Services (2024). The full source is linked on this page so you can read it yourself.
Is this medical advice?
This is information to bring to your prescriber, not medical advice and not a reason to change anything on your own. Nothing here is an instruction to stop or reduce a medication. If you are in crisis, call or text 988.
This is information to bring to your prescriber, not medical advice and not a reason to change anything on your own. Nothing here is an instruction to stop or reduce a medication. If you are in crisis, call or text 988.