CMS HCC V28 and the Future of Risk Adjustment: What Providers Need to Know

Healthcare providers face constant challenges in adapting to evolving documentation rules, especially amidst the growing population of patients with chronic conditions. Many providers still rely on workflows established during the CMS HCC V24 era, but the transition from CMS HCC V24 to V28 significantly amplifies the pressure. With increased coding specificity and heightened compliance scrutiny, providers require smarter strategies and dependable Risk Adjustment Vendors to effectively bridge care delivery with accurate reimbursement.

Why the CMS HCC V28 Update Matters

The shift from CMS HCC V24 to V28 isn’t simply an incremental update—it’s a comprehensive move towards greater clinical accuracy and reimbursement alignment. This refined model excludes some previously accepted HCC codes, consolidates others, and introduces reclassifications, fundamentally altering risk adjustment dynamics. These changes drastically reduce coding error margins but place unprecedented importance on documentation accuracy. Providers must rethink diagnosis capture practices across patient encounters to maintain compliance and reimbursement stability.

Key Shifts from CMS HCC V24 to V28 and Their Implications

1. Diagnosis Code Reduction

CMS HCC V28 notably reduces valid diagnosis codes, retaining only those with high predictive accuracy for future healthcare costs. This strategic reduction can inadvertently lead to a decline in Risk Adjustment Factor (RAF) scores if previously adjustable conditions no longer qualify.

2. Reorganized Condition Categories

Condition categories have undergone significant restructuring to better reflect clinical realities. Providers must update documentation templates and adopt new coding guidelines to remain compliant and accurate in reporting.

3. Hierarchical Updates

V28 has updated condition hierarchies, affecting how individual conditions contribute to RAF scores. Coders must recognize and correctly apply these new hierarchical relationships to ensure all legitimate conditions continue contributing to overall risk scores.

4. Increased Audit Scrutiny

As coding opportunities shrink, CMS is increasing its audit intensity. Providers must deliver precise, detailed documentation supported by MEAT (Monitor, Evaluate, Assess, Treat) criteria to withstand scrutiny from RADV and OIG audits.

Actionable Strategies to Adapt to CMS HCC V28

Refresh CDI and Provider Training Programs
Updating stakeholders on the changes from CMS HCC V24 to V28 is critical. Special attention should be given to conditions excluded in the new model and to newly established documentation requirements. Clear training ensures everyone from clinicians to coders is aware of the standards necessary for accurate risk adjustment.

Reevaluate Documentation Templates and Tools
Providers should immediately audit and revise electronic medical record (EMR) templates and smart phrases to align with V28. Removing outdated prompts reduces confusion and ensures clinicians document accurately according to new guidelines.

Collaborate Closely with Risk Adjustment Vendors
Partnering with expert Risk Adjustment Vendors provides valuable benchmarking, continuous audit readiness, and AI-powered tools that quickly identify documentation gaps. Such collaborations enable providers to address potential issues proactively, avoiding significant revenue impacts.

Utilize Predictive Analytics to Guide Provider Focus
Implementing predictive analytics tools enables clinical teams to identify patients at high risk of documentation gaps prior to visits, facilitating targeted patient-provider discussions. This approach supports proactive rather than reactive documentation.

Conduct Targeted Chart Audits
Perform concurrent reviews to promptly identify documentation discrepancies related to V28 exclusions or reclassifications, addressing issues swiftly rather than relying solely on retrospective corrections.

Future Implications: CMS HCC V28 and the Direction of Risk Adjustment

More Focused, Less Inflated RAF Scores
The intent of CMS HCC V28 is clear: reducing the potential for risk score inflation by more closely aligning reimbursement with genuinely high-cost, high-impact patient conditions. Providers must ensure precision and clarity in documenting such conditions.

Greater Accountability Across the Care Team
Risk adjustment will no longer solely depend on coding specialists. Successful RAF capture requires integrated efforts among clinical, administrative, and technical teams. All stakeholders need to understand their roles clearly and collaborate effectively.

Increased Demand for Interoperable Tools
Future risk adjustment workflows will heavily depend on interoperable systems that seamlessly communicate across EHRs, coding platforms, and analytics engines. Providers will increasingly seek unified solutions that enhance accuracy and efficiency.

The Rise of Prospective and Concurrent Workflows
Real-time documentation and concurrent coding practices are now essential. Retrospective approaches will become inadequate under the stringent standards imposed by CMS HCC V28, emphasizing the urgency for proactive compliance.

Missteps Providers Must Avoid During the Transition

Underestimating the Impact of V28
Providers who treat V28 merely as another incremental coding update underestimate its fundamental changes. Recognizing V28 as a strategic shift in CMS’s philosophy toward patient risk measurement is crucial to maintaining compliance and revenue.

Delaying Education Until Denials Occur
Proactive education mitigates risks before costly errors occur. Providers who delay training until after experiencing revenue loss from denials place their organizations at unnecessary financial risk.

Overlooking the Value of Vendor Partnerships
Given the complexity of CMS HCC V28, providers benefit significantly from experienced Risk Adjustment Vendors who offer critical insights, comprehensive support, and robust data validation. Ignoring such partnerships can severely limit the organization’s capacity for accuracy and compliance.

Building Credibility and Trust Through EEAT Principles

Providers transitioning successfully to V28 demonstrate Experience through early adoption and proven accuracy improvements. They leverage Expertise by staying current with CMS documentation, ensuring their practices align strictly with official guidelines. Authority is established through deep understanding and clear communication of clinical and compliance strategies, while Trust is built by offering precise, actionable guidance validated by emerging trends and established CMS expectations.

Conclusion: Why Immediate Action is Imperative

The move from CMS HCC V24 to V28 signals more than compliance adjustments—it represents an opportunity to fundamentally modernize risk adjustment strategies. Providers who remain passive risk significant revenue losses and compliance challenges. Conversely, early adopters aligning with forward-thinking Risk Adjustment Vendors will secure financial stability, gain strategic advantages, and ensure sustainable excellence in patient care delivery and documentation accuracy.