Anyone working in risk adjustment knows that model updates are part of the job. What’s different about CMS-HCC V28 is how quickly it shows up in everyday coding decisions.
Many organizations are already rethinking how they capture, document, and code patient conditions. These model updates are part of a broader effort by CMS to better align documented patient complexity with coding accuracy and consistency. That said, implementation can involve operational and documentation challenges.
For coding teams, providers, and compliance leads, the challenge is increasingly clear: a key focus area is ensuring that documentation and coding practices keep pace with the model’s increased demand for clinical accuracy.
For many organizations, this is more than just a system update. It changes how teams document, code, and review patient records in everyday workflows. Organizations that proactively adapt are often better positioned to maintain coding accuracy, strengthen compliance, and reduce the risk of under-reporting or unsupported reporting of patient complexity.
What the V28 Model Changes Mean for Risk Adjustment
At its core, V28 introduces greater specificity and structural precision within the model.
Some HCC categories have been removed or consolidated, and the overall structure now places more weight on clearly defined, well-supported diagnoses. This reduces overlap but also reduces variability in how conditions are captured.
A few practical implications organizations are already noticing:
1. Reduced reliance on carry-forward documentation
Diagnoses that were previously carried forward across encounters may now require more active, encounter-specific documentation to contribute.
2. Reduced impact of less specific coding
Less specific terminology without sufficient clinical detail may be less likely to map effectively.
3. More dependence on current encounter documentation
What gets documented during the current encounter is becoming significantly more important than what sits in the patient’s historical record.
The intent behind V28 is fairly straightforward, making risk adjustment more accurate and consistent across the board. While exact impacts vary by organization, early analyses have shown noticeable RAF score redistribution across populations, especially where documentation lacked specificity.
Diagnoses That Require Greater Documentation Specificity
This is where many organizations are experiencing the most adjustment. The conditions themselves haven’t changed. What has changed is the level of precision required in how they are documented to support accurate coding.
Heart Failure
- Type (systolic, diastolic, combined) and acuity (acute, chronic, acute on chronic) matter
- Missing descriptors directly impact coding outcomes
Behavioral Health Conditions
- Must show active management or clinical relevance
- Unsupported or outdated diagnoses are subject to increased review
Morbid Obesity
Documenting obesity alone may not fully capture patient complexity.
Specific classification, such as BMI range or severity, along with its impact on care, helps support more accurate coding.
A consistent theme across these categories is the need for clinically supported, encounter-specific documentation. Unsupported historical diagnoses or carry-forwards without current assessment may be more challenging to support during audits under V28.
Coding Workflow Adjustments Organizations Are Making
To align with V28 requirements, many organizations are revisiting their coding workflows and making targeted adjustments.
In practice, several shifts are emerging across organizations:
1. More proactive chart reviews
- Concurrent or pre-visit reviews are becoming more common
- This allows teams to identify opportunities to strengthen documentation earlier
2. Targeted provider education
- Focused sessions based on actual documentation gaps
- Use of specialty-specific examples rather than generic training
3. Stronger use of analytics
- Identifying cases where documentation may not fully reflect clinically evaluated conditions
- Tracking patterns in documentation specificity and coding consistency
4. Closer alignment between coding and clinical teams
- Faster clarification loops
- Better understanding of documentation intent vs coding requirements
5. Selective outsourcing or expert support
Some organizations also engage external partners, such as MedCode, to support internal teams with scale, secondary reviews, or complex case validation.
The Role of Risk Adjustment Reviews in Navigating V28
Risk adjustment reviews are becoming increasingly central in the V28 environment. They act as both a quality control mechanism and a strategic tool for accuracy.
1. Prospective Reviews
These happen before, or sometimes during, the patient encounter, and they are becoming increasingly important.
They help:
- Highlight clinically relevant conditions that may benefit from further documentation review
- Prompt providers to clarify documentation where clinical detail may be incomplete
- Support accurate capture of active, clinically supported conditions
2. Retrospective Reviews
Still essential, especially when it comes to validation and compliance.
They focus on:
- Verifying coding accuracy
- Identifying conditions that were evaluated but may require more complete documentation or coding alignment
- Supporting audit readiness
Together, these approaches create a more comprehensive review ecosystem. They not only support accurate and compliant RAF representation but also reduce the likelihood of errors that could lead to compliance concerns.
In practice, organizations that operationalize both review types effectively, often with structured workflows or support from experienced platforms such as MedCode, aim to achieve more consistent alignment between clinical documentation and coding outcomes.
Importantly, reviews must be grounded in clinical evidence. Any identified diagnosis must be supported by clear documentation in the medical record.
At the same time, maintaining this balance between accuracy and compliance is not always straightforward. Teams often need to navigate situations where clinical context may be understood but not fully reflected in documentation.
In such cases, the focus shifts from identifying additional conditions to ensuring that existing documentation is complete, clear, and aligned with coding requirements. This distinction is subtle but increasingly important under V28.
Preparing Risk Adjustment Programs for Future Model Updates
V28 isn’t a one-time adjustment. It’s part of a longer shift.
Organizations that treat it as such are better positioned for long-term success.
- Expect Continuous Model Evolution : CMS updates are ongoing. Building flexible processes is more effective than reacting each time.
- Develop Flexible Coding Frameworks: Systems that can adjust without major disruption reduce long-term operational strain.
Strengthen documentation improvement efforts
- Real-time provider feedback
- Continuous monitoring of documentation quality
- Specialty-focused guidance
- Maintain strong compliance frameworks:Increased specificity also brings greater emphasis on audit readiness and documentation clarity. Clear audit trails and defensible coding practices are critical. This includes ensuring all coded conditions meet MEAT criteria (Monitored, Evaluated, Assessed, Treated) and are supported within the encounter documentation.
- Leverage Technology Thoughtfully: AI and analytics tools can support risk adjustment efforts, particularly in highlighting documentation opportunities or helping prioritize reviews, but they still depend on accurate clinical input and appropriate human validation.
Frequently Asked Questions
1. How does V28 affect RAF scores?
RAF scores may change under V28 because some conditions now require more specific and current documentation to be counted. If that detail is missing, the score may drop, even if the patient’s condition hasn’t actually changed.
2. Are retrospective reviews still necessary?
Yes. While prospective reviews help improve capture, retrospective reviews are essential for validating accuracy and maintaining compliance.
3. What is the biggest challenge organizations are facing?
The most common challenge is aligning provider documentation with the level of specificity required under the updated model.
4. Does V28 reduce HCC categories?
Yes, certain categories have been consolidated or removed to improve clarity and reduce redundancy.
5. How can organizations adapt effectively?
By focusing on
- Improving documentation specificity
- Strengthening review processes
- Using data to identify gaps
- Supporting providers with targeted education
Conclusion
V28 isn’t turning risk adjustment upside down, but it is encouraging teams to adopt greater precision. The fundamentals of risk adjustment haven’t changed, but the margin for vague or incomplete documentation has narrowed.
Organizations that respond with practical workflow changes, stronger documentation practices, and consistent review processes are better positioned to manage both accuracy and compliance.
This does not represent a complete reset, but it does demand closer attention than before. And a willingness to refine how coding and documentation come together in everyday practice.
