Understanding CMS HCC Model V28 Changes: What Health Plans Need to Know

The rollout of CMS HCC model V28 introduces a series of important updates that health plans must understand to navigate risk adjustment effectively. These changes affect how chronic conditions are categorized, weighted, and documented, impacting both reimbursement and compliance. By gaining a clear grasp of the new model’s nuances, health plans can proactively adapt their strategies to capture patient risk accurately and sustain financial stability.

Key Shifts in Condition Groupings and Hierarchies

One of the primary updates in V28 involves the reorganization of hierarchical condition categories. Some diagnoses have been reclassified or combined, while others have been removed or redefined. This reshaping affects how overlapping conditions contribute to risk scores and requires health plans to reassess their documentation and coding practices.

Understanding these shifts is essential because they determine which conditions carry more weight and which may no longer influence risk adjustment as before. Health plans that adjust quickly can avoid revenue loss due to missed or outdated coding practices and better align with CMS expectations.

Increased Emphasis on Specificity and Clinical Detail

CMS HCC model V28 places stronger emphasis on clinical specificity. Vague or general diagnoses that previously qualified for risk adjustment may no longer suffice. Documentation must include precise details such as disease stage, severity, and causal relationships to meet the new standards.

For health plans, this means provider education and documentation policies must evolve. Clinical teams need clear guidance on capturing necessary details at the point of care, supported by clinical documentation improvement programs and concurrent coding strategies.

Implications for Audit Preparedness

With the new model’s heightened focus on specificity, audit risk also increases. CMS and its contractors are intensifying reviews, particularly around documentation that supports hierarchical categories under V28. Health plans must ensure that their retrospective reviews, audit readiness processes, and compliance programs reflect the updated guidelines.

Proactively aligning internal audits and query processes with V28 requirements can reduce the risk of denials, recoupments, and penalties. Additionally, fostering collaboration between CDI, coding, and clinical teams strengthens the ability to produce defensible documentation.

Leveraging Technology to Navigate the Transition

Technology plays a critical role in adapting to CMS HCC model V28. Risk adjustment platforms that integrate AI-driven clinical natural language processing and real-time documentation prompts can help providers capture detailed information accurately and consistently.

These tools also assist coders by highlighting potential gaps or inconsistencies in documentation based on the latest model rules. By embedding these capabilities into workflows, health plans can reduce errors and accelerate the transition to V28-compliant coding practices.

Conclusion

CMS HCC model V28 brings meaningful changes that require health plans to reevaluate their documentation, coding, and compliance strategies. Understanding these updates and responding proactively is vital to preserving revenue integrity and audit readiness. By focusing on clinical specificity, updating training, strengthening audit processes, and leveraging advanced technology, health plans can successfully navigate the transition and position themselves for sustained success under the new model.