Table IV-4. CMS-HCC Community and Institutional Models for Functioning Graft [1] Additional payment factors for functioning graft status are at bottom of table. Variable,Disease Group,Community Relative Factor,Constraints [2],Institutional Relative Factor,Constraints [2] Age/Sex Groups Female0_34,,0.117,,1.064 Female35_44,,0.197,,1.064 Female45_54,,0.214,,1.064 Female55_59,,0.265,,1.064 Female60_64,,0.375,,1.064 Female65_69,,0.307,,1.164 Female70_74,,0.384,,1.179 Female75_79,,0.483,,0.992 Female80_84,,0.572,,0.938 Female85_89,,0.665,,0.88 Female90_94,,0.795,,0.789 Female95_GT,,0.805,,0.581 Male0_34,,0.068,,1.104 Male35_44,,0.12,,1.104 Male45_54,,0.19,,1.104 Male55_59,,0.27,,1.104 Male60_64,,0.342,,1.104 Male65_69,,0.346,,1.45 Male70_74,,0.453,,1.238 Male75_79,,0.577,,1.211 Male80_84,,0.657,,1.209 Male85_89,,0.79,,1.241 Male90_94,,0.901,,1.049 Male95_GT,,1.035,,0.836 Medicaid and Originally Disabled Interactions with Age and Sex [5] ,,,,0 Medicaid_female_disabled,,0.221,,0 Medicaid_female_aged,,0.183,,0 Medicaid_male_disabled,,0.115,,0 Medicaid_male_aged,,0.184,,0 "Female, 65+, originally entitled due to disability",,0.236,,0 "Male, 65+, originally entitled due to disability",,0.148,,0 ,, ,, Disease Group Factors,, ,, HCC1,HIV/AIDS,0.685,,1.344,C1 HCC2,Septicemia/Shock,0.89,,0.946 HCC5,Opportunistic Infections,0.652,,1.344,C1 HCC7,Metastatic Cancer and Acute Leukemia,1.464,,0.54 HCC8,"Lung, Upper Digestive Tract, and Other Severe Cancers",1.464,,0.54 HCC9,"Lymphatic, Head and Neck, Brain and Other Cancers",0.69,,0.452 HCC10,"Breast, Prostate, Colorectal and Other Cancers and Tumors",0.233,,0.259 HCC15,Diabetes with Renal or Peripheral Circulatory Manifestation,0.764,,0.612 HCC16,Diabetes with Neurologic or Other Specified Manifestation,0.552,,0.612 HCC17,Diabetes with Acute Complications,0.391,,0.612 HCC18,Diabetes with Ophthalmologic or Unspecified Manifestation,0.343,,0.612 HCC19,Diabetes without Complication,0.2,,0.255 HCC21,Protein-Calorie Malnutrition,0.922,,0.427 HCC25,End-Stage Liver Disease,0.9,,0.268 HCC26,Cirrhosis of Liver,0.516,,0.268 HCC27,Chronic Hepatitis,0.359,,0.268 HCC31,Intestinal Obstruction/Perforation,0.408,,0.268 HCC32,Pancreatic Disease,0.445,,0.268 HCC33,Inflammatory Bowel Disease,0.307,,0.268 HCC37,Bone/Joint/Muscle Infections/Necrosis,0.496,,0.495 HCC38,Rheumatoid Arthritis and Inflammatory Connective Tissue Disease,0.322,,0.285 HCC44,Severe Hematological Disorders,1.011,,0.448 HCC45,Disorders of Immunity,0.83,,0.448 HCC51,Drug/Alcohol Psychosis,0.353,,0.221 HCC52,Drug/Alcohol Dependence,0.265,,0.221 HCC54,Schizophrenia,0.543,,0.221 HCC55,"Major Depressive, Bipolar, and Paranoid Disorders",0.431,,0.221 HCC67,"Quadriplegia, Other Extensive Paralysis",1.181,,0.098,C2 HCC68,Paraplegia,1.181,,0.098,C2 HCC69,Spinal Cord Disorders/Injuries,0.492,,0.098,C2 HCC70,Muscular Dystrophy,0.386,,0.098,C2 HCC71,Polyneuropathy,0.268,,0.098,C2 HCC72,Multiple Sclerosis,0.517,,0.098,C2 HCC73,Parkinson's and Huntington's Diseases,0.475,,0.098,C2 HCC74,Seizure Disorders and Convulsions,0.269,,0.098,C2 HCC75,"Coma, Brain Compression/Anoxic Damage",0.568,C1,0.098,C2 HCC77,Respirator Dependence/Tracheostomy Status,2.102,,1.415 HCC78,Respiratory Arrest,1.429,,1.415 HCC79,Cardio-Respiratory Failure and Shock,0.692,,0.289 HCC80,Congestive Heart Failure,0.417,,0.176 HCC81,Acute Myocardial Infarction,0.348,,0.288 HCC82,Unstable Angina and Other Acute Ischemic Heart Disease,0.348,,0.288 HCC83,Angina Pectoris/Old Myocardial Infarction,0.235,,0.288 HCC92,Specified Heart Arrhythmias,0.266,,0.187 HCC95,Cerebral Hemorrhage,0.392,,0.151 HCC96,Ischemic or Unspecified Stroke,0.306,,0.151 HCC100,Hemiplegia/Hemiparesis,0.437,,0.098,C2 HCC101,Cerebral Palsy and Other Paralytic Syndromes,0.164,,0.098,C2 HCC104,Vascular Disease with Complications,0.677,,0.509 HCC105,Vascular Disease,0.357,,0.114 HCC107,Cystic Fibrosis,0.376,,0.23 HCC108,Chronic Obstructive Pulmonary Disease,0.376,,0.23 HCC111,Aspiration and Specified Bacterial Pneumonias,0.693,,0.463 HCC112,"Pneumococcal Pneumonia, Emphysema, Lung Abscess",0.202,,0.463 HCC119,Proliferative Diabetic Retinopathy and Vitreous Hemorrhage,0.349,,0.995 HCC130 [4],Dialysis Status,0,,0 HCC131 [4],Renal Failure,0,,0 HCC132,Nephritis,0.273,,0.42 HCC148,Decubitus Ulcer of Skin,1.03,,0.317 HCC149,"Chronic Ulcer of Skin, Except Decubitus",0.484,,0.262 HCC150,Extensive Third-Degree Burns,0.962,,0.248,C3 HCC154,Sever Head Injury,0.568,C1,0.248,C3 HCC155,Major Head Injury,0.242,,0.248,C3 HCC157,Vertebral Fractures without Spinal Cord Injury,0.49,,0.098,C2 HCC158 [5],Hip Fracture/Dislocation,0.392,,0 HCC161,Traumatic Amputation,0.843,C2,0.248,C3 HCC164,Major Complications of Medical Care and Trauma,0.262,,0.263 HCC174,Major Organ Transplant Status,0.261,,0.319 HCC176,Artificial Openings for Feeding or Elimination,0.79,,0.882 HCC177,"Amputation Status, Lower Limb/Amputation Complications",0.843,C2,0.248,C3 ,, ,, Disabled/Disease Interactions [5],, ,, D_HCC5 [5],<65*Opportunistic Infections,0.789,,0 D_HCC44 [5],<65*Severe Hematological Disorders,0.893,,0 D_HCC51 [5],<65*Drug/Alcohol Psychosis,0.509,,0 D_HCC52 [5],<65*Drug/Alcohol Dependence,0.414,,0 D_HCC107 [5],<65*Cystic Fibrosis,1.861,,0 ,, ,, Disease Interactions [3],, ,, INT1,DM_CHF,0.253,,0.207 INT2 [5],DM_CVD,0.125,,0 INT3,CHF_COPD,0.241,,0.372 INT4 [5],COPD_CVD_CAD,0.079,,0 INT5 [4],RF_CHF,0,,0 INT6 [4],RF_CHF_DM,0,,0 ,, ,, Graft Factors [6],, ,, "<65, with duration since transplant of 4-9 months",,3.091,,3.091 "65+, with duration since transplant of 4-9 months",,3.425,,3.425 "<65, with duration since transplant of 10 months or more",,1.62,,1.62 "65+, with duration since transplant of 10 months or more",,1.691,,1.691 Notes: "[1] To determine payment for persons with functioning grafts, the computed risk factor should be applied to the appropriate cell in the CMS-HCC county risk ratebook for the aged and disabled. For payment in any month, duration is measured from the month of transplant to the first day of that month. All coefficients except for the graft factors and HCC174 are restricted to the values estimates for the CMS-HCC payment models." "[2] means coefficients of HCCs are constrained to be equal, and C1, C2, and C3 denote non-contiguous constraints. For the community model C1=0.568, and C2=0.843; for the institutional model C1=1.344. C2=0.098, and C3=0.248." [3] Diseases in interactions are: DM= diabetes mellitus (HCCs 15-19) CHF= congestive heart failure (HCC 80) COPD= chronic obstructive pulmonary disease (HCC 108) "CVD= cerebrovascular disease (HCCs 95-96, 100-101)" CAD= coronary artery disease (HCCs 81-83) RF= renal failure (HCC 131) [4] These HCC's are not in the model for those in functioning graft status. [5] These HCCs not present in institutional model. "[6] The graft factors are additive, similar to any other factors in the CMS-HCC model. The factor is higher during the months immediately after transplant to account for a high level of monitoring and services."