V24 to V28
1. CMS-HCC V28: Phased Implementation, RAF Impacts, and Major Coding Shifts
The CMS-HCC Version 28 Risk Adjustment Model is one of the most significant updates in Medicare Advantage (MA) payment methodology in recent years. This phased rollout brings with it sweeping changes in diagnosis mapping, HCC structure, and RAF calculations that will impact provider documentation, MAO revenue, and CMS payments.
Here’s what MA plans, coders, and providers need to know.
🔄 Phased Implementation Timeline
PY 2024: 67% RAF scores from V24, 33% from V28
PY 2025: 33% RAF scores from V24, 67% from V28
PY 2026: 100% RAF scores based on V28
MAOs need dual-model readiness now to manage this transition. Health plans must revise analytics models, retrain staff, and prepare providers for documentation expectations aligned to the V28 logic. Since scoring methodologies will blend in 2024 and 2025, dual-mapped submissions and comparative impact assessments are essential.
📈 Key Model Updates in V28
Uses 2018 diagnosis and 2019 expenditure data, creating more current alignment
Enhanced model reflects clinically stable and predictive diagnoses, improving precision
Stronger mapping with modern ICD-10 code structure results in greater granularity and fewer misclassifications
These upgrades ensure risk scoring keeps pace with evolving coding standards and clinical guidelines.
🔢 Diagnosis & HCC Category Changes
Diagnoses Mapped
The number of diagnoses mapped to HCCs has decreased from 9,797 in V24 to 7,770 in V28. This reduction ensures only clinically relevant and cost-predictive diagnoses are retained.
Payment HCCs Expanded
V24 had 86 payment HCC categories.
V28 expands this to 115, allowing for more nuanced representation of patient conditions and risk.
New HCCs Added in V28
209 new ICD-10-CM codes have been mapped to HCCs in V28.
Many of these are focused on capturing conditions with stronger predictive value, including behavioral health and rare diseases.
Significant Removals
V28 removes 2,236 ICD-10-CM codes that were previously mapped to HCCs in V24.
These codes were excluded for having weak associations with future healthcare costs or poor documentation support
Fewer mapped diagnoses in V28 reflect CMS's goal of eliminating codes with poor predictive value and ensuring every code that contributes to the RAF score has strong clinical justification.
➕ Notable New HCC Additions
HCC 298 – Retinal Vein Occlusion
HCC 279 – Severe Persistent Asthma
HCC 153 – Eating Disorders (Anorexia, Bulimia)
HCC 22 – Benign Carcinoid Tumor
HCC 17 – Malignant Pleural Effusion
These additions better capture high-acuity patients whose conditions were previously unrecognized under the payment model.
🚫 Removed HCCs (Examples)
HCC 21 – Protein Calorie Malnutrition
HCC 23 – Parathyroid & Metabolic Diseases
HCC 88 – Angina Pectoris
HCC 59 – Mild Major Depression, Substance Abuse
HCC 134/135 – Dialysis Status, Acute Renal Failure
Removing these codes improves model integrity but may reduce scores for members with low-cost, non-predictive conditions. Providers must stay informed to avoid coding obsolete diagnoses.
♻ Renumbering and Group Expansion
Neoplasm group expanded from 5 to 7 HCCs, creating better differentiation across tumor types
Other categories, such as vascular and endocrine conditions, were similarly expanded and refined
🔀 Dual HCC Mapping (Examples)
Diabetes with macular edema → HCC 37 + HCC 298
Heart-lung transplant complications → HCC 221 + HCC 276
Dual-mapped codes reflect the complexity of some conditions that span multiple organ systems or complications. They provide richer context for RAF calculation and stratification.
📆 Constraining and RAF Score Impacts
V28 constrains RAF values by grouping diagnoses with similar cost profiles
Equal coefficient values now apply to some conditions regardless of severity or complications
For example, diabetes with and without complications may now carry the same RAF
CMS projects an average RAF decrease of 3.12% for MA plans in 2024
Estimated $11B in Medicare Trust Fund savings expected from V28 changes in 2024 alone
Plans must recalibrate revenue expectations and prepare coding workflows that prioritize fully supported, risk-adjustable diagnoses.
📅 Key Changes in V28 Summary
HCCs increased from 86 to 115, reflecting updated clinical classification
2,294 ICD-10-CM codes removed from contributing to RAF
268 new codes added, 40% related to perinatal and congenital categories
Conditions with inflated RAFs in V24 (e.g., Protein Calorie Malnutrition, T2DM without complications) have been reduced or removed
🧱 Implications for Providers and MAOs
Precise, compliant ICD-10-CM coding is now mission critical
Provider documentation must clearly support code selection and demonstrate condition severity
MAOs must:
Expand chart review programs
Strengthen clinical documentation improvement (CDI) initiatives
Integrate model-specific education for coding teams
Financial impact will vary based on member case mix, provider readiness, and coding accuracy
✅ Final Word
CMS-HCC V28 transforms how Medicare Advantage risk scores are derived. With increased specificity, updated mappings, and new RAF logic, the model rewards accurate, clinically supported documentation.
Plans and providers who start preparing now will not only ensure compliance, but also protect risk-adjusted revenue in 2024, 2025, and beyond.
2. Mental & Behavioral Health Risk Adjustment: Major Changes Under V28
What's Changing in V28?
Under CMS-HCC Version 28, the risk adjustment model has been significantly revised—particularly in the domain of mental and behavioral health. One of the most notable changes is the removal of depression and anxiety diagnoses from the list of risk-adjusting conditions.
V24 vs. V28: Mental Health Coding Comparison
In the older Version 24 model:
Conditions like Major Depressive Disorder (F33.1) and generalized anxiety were mapped to HCCs and contributed to risk scores.
In Version 28, those diagnoses have been excluded. Now, only major neurocognitive disorders continue to qualify for risk adjustment under mental and behavioral categories.
✅ Still Risk-Adjusting in V28:
G30.x – Alzheimer’s disease
F01.x – Vascular dementia
❌ No Longer Risk-Adjusting:
F33.x – Major Depressive Disorder
F41.x – Anxiety disorders
F32.x – Depressive episodes
This is a substantial change for coders and Medicare Advantage Organizations (MAOs), as these diagnoses were commonly used in the risk adjustment process under V24.
Why This Matters for MAOs
Removing common psychiatric diagnoses from the model can reduce risk scores, directly impacting plan revenue and care coordination strategies. It also forces a sharper focus on clinical documentation and specificity, especially for cognitive disorders that still qualify.
Clinical Coding Tip: Focus on Supporting Documentation
To ensure accurate and compliant coding under V28, providers and coders should focus on capturing strong clinical indicators that validate neurocognitive diagnoses.
Recommended Documentation to Include:
MMSE (Mini-Mental State Exam) Scores
A validated cognitive screen helps support Alzheimer’s or dementia diagnoses.Neuropsychological Evaluations
These reports strengthen diagnostic accuracy and are valuable for audit protection.Behavioral Health Notes
Detailed documentation from psychiatrists, neurologists, or behavioral health specialists offers supporting context.
💬 Functional Impact Notes
Describe how the cognitive condition affects daily living and care needs.
What MAOs Should Do Now
If your organization relies on behavioral health conditions in its risk adjustment strategy, now is the time to realign your approach.
Action Steps:
Update internal HCC crosswalks to reflect V28 mappings.
Educate providers and coders about the loss of MDD/anxiety from the risk model.
Audit documentation to identify patients who may qualify under neurocognitive HCCs instead.
Enhance training on recognizing and documenting G30.x and F01.x codes properly.
Engage behavioral health teams to update workflows in light of these changes.
Final Thoughts
The shift to CMS-HCC Version 28 marks a narrowing of scope for mental and behavioral health conditions. MAOs must proactively respond to these changes by adjusting documentation strategies, educating stakeholders, and closely monitoring diagnosis data.
While depression and anxiety no longer impact risk scores, the accurate capture of qualifying neurocognitive conditions can still make a measurable difference.
3. Why V28 HCC Coding Demands Sharper Clinical Precision: Key Changes and Tips
A New Era of Clinical Specificity
If you thought HCC coding was tricky before, buckle up — with V28, it just got even more nuanced! CMS’s latest model strips away more than 2,200 ICD-10 codes that once mapped to payment HCCs under the V24 model. This means general diagnoses like hyperlipidemia (E78.5) or unspecified diabetic complications no longer automatically help with risk adjustment.
Now, coders must prove specificity. It’s no longer enough to say someone has "diabetes with other complications." You need to nail down exactly what complication — backed by solid clinical evidence.
What’s Changed from V24 to V28?
In simple terms: less guesswork, more precision.
Here’s a real-world coding comparison to make it crystal clear:
V24:
E11.69 — Diabetes mellitus with other complication → Mapped to an HCC
V28:
- E11.69 — Nope, no longer cuts it.
Instead, you need to document specifically, like:- E11.22 — Type 2 diabetes with chronic kidney disease
- E11.319 — Type 2 diabetes with unspecified diabetic retinopathy
Bottom line: The burden is now on clinicians to document and coders to code specific, clinically validated conditions.
Why Does This Matter?
Well, a couple of big reasons:
Risk Adjustment Payments: Fewer mapped diagnoses mean lower risk scores if specificity isn’t captured.
Clinical Accuracy: It pushes healthcare providers toward more accurate patient records, which (bonus!) also improves patient care.
Audit Readiness: Less ambiguity = stronger protection in case of audits.
In short, without precise documentation, organizations could lose out on appropriate reimbursements and open themselves up to compliance risks. Not exactly the party you want to be at, right?
Clinical Coding Tip: Be Specific, or Be Sorry
How do you thrive under V28? Here’s your cheat sheet:
Use Lab Data: Confirm complications like CKD with lab results (e.g., eGFR levels).
Leverage Imaging Reports: Radiology can validate conditions like diabetic retinopathy or chronic heart failure.
Pull in Consults: Specialist notes are golden for justifying nuanced diagnoses like nephropathy or neuropathy.
Avoid “Unspecified” Diagnoses: Whenever possible, go hunting for the specifics in the EHR (Electronic Health Record).
Educate Providers: Quick provider education sessions can make a massive difference in documentation quality.
A Quick Example to Bring It Home:
Suppose a patient has diabetes and their labs show early-stage CKD (Chronic Kidney Disease).
Instead of coding a general diabetes complication, here’s what to do:
Wrong way (V24 mindset):
Code E11.69 — Diabetes with other complication.Right way (V28 precision):
Code E11.22 — Diabetes with chronic kidney disease.
Simple enough when you know what to look for, right?
FAQs
Q: Which diagnoses are most impacted by the V28 changes?
A: Common general codes like hyperlipidemia (E78.5) and unspecified diabetic complications are among the major ones. Always double-check for specificity now.
Q: How can coders adapt quickly to V28?
A: Invest time in cross-training with clinical staff, use clinical data smartly, and set up internal audits to catch gaps early.
Q: Will these changes impact risk scores significantly?
A: You bet! Less specificity = lower scores. Higher specificity = accurate, defendable scores.
Wrapping It Up: Precision is Your Power Move
The shift from V24 to V28 isn’t just another coding update — it’s a complete mindset change. With over 2,200 fewer risk-adjusting codes, your documentation game must be razor-sharp.
Action Steps:
Get cozy with lab, imaging, and consult data.
Train providers to document clearly and specifically.
Audit early and often to catch mistakes before they cost you.
Remember, precision isn’t just about payment — it’s about better care, stronger compliance, and smarter coding. You've got this!
Helpful External Resources:
4. Chronic Conditions Must Show Active Management in Risk Adjustment
In the transition from CMS-HCC V24 to V28, chronic conditions like Chronic Kidney Disease (CKD) and Chronic Obstructive Pulmonary Disease (COPD) remain risk-adjusting—but coding alone isn’t enough. To ensure these diagnoses hold up under scrutiny and contribute to accurate reimbursement, clinical documentation must demonstrate ongoing management.
Why This Matters in V28
Let’s look at how these chronic conditions are handled in the latest CMS-HCC model:
1. N18.32 – CKD, Stage 3b
HCC in V28: 328
Category: Moderate Chronic Kidney Disease (Stage 3b)
Relative Factor: 0.127
2. J44.9 – COPD, unspecified
HCC in V28: 280
Category: Chronic Obstructive Pulmonary Disease
Relative Factor: 0.319
While both diagnoses still map to HCCs, V28 emphasizes specificity and supporting clinical evidence more than ever. Payers and auditors expect clear, current indicators that the condition is being actively managed—not just mentioned.
🧪 Clinical Evidence That Supports CKD and COPD
N18.32 – CKD Stage 3b
To validate this diagnosis, your documentation should reflect:
GFR values consistently in the 30–44 range
Ongoing nephrology involvement
Regular labs: creatinine, BUN, electrolytes
Medication reviews (e.g., ACE inhibitors or ARBs)
J44.9 – COPD
To support this diagnosis under audit:
PFT results (showing FEV1/FVC < 0.7)
Prescribed inhalers or nebulizers
Specialist visits with pulmonology
Symptom notes: chronic cough, dyspnea, exacerbation history
💡 Coding Tip: Link Diagnosis to Action
Coders must go beyond just capturing the diagnosis. Each encounter note should tie the chronic condition to a current assessment or plan:
Is the provider monitoring labs?
Was medication adjusted or prescribed?
Are symptoms being evaluated?
Without this level of detail, diagnoses like J44.9 or N18.32 may be excluded during risk adjustment filtering or flagged during RADV audits.
🔍 Final Thoughts
CMS’s V28 model continues to risk-adjust chronic conditions, but demands higher clinical specificity and documentation rigor. AI-enabled coding audits and encounter reviews can help flag insufficient documentation before submission—ensuring each diagnosis truly holds up.
Want to ensure your team is coding and documenting to V28 standards? Let’s talk
5. V28 HCC Coding for Heart Failure: Why EF and Specificity Matter
A New Era of Cardiac Coding: What V28 Means for Heart Failure Documentation
The transition from CMS-HCC V24 to V28 has brought massive changes to how risk adjustment coding works — and one of the biggest shifts is in how heart failure needs to be documented and coded.
In the V24 model, you might’ve been able to get by with a general heart failure diagnosis. Not anymore. Under V28, specificity is king — and if you’re not documenting the type, chronicity, and supporting EF data, you're not just losing out on risk score points... you’re risking compliance issues.
So what exactly does this mean in practice? Let’s break it down.
The Core of It: Why EF, Type, and Chronicity Are Critical
If you're coding heart failure under V28, you must answer three questions:
What type of heart failure is it? (Systolic? Diastolic? Combined?)
Is it chronic, acute, or acute-on-chronic?
Do you have clinical evidence like an echocardiogram to support it?
Without clear answers to these, codes like I50.9 (Heart failure, unspecified) won’t map to an HCC anymore — and that’s a major issue if you’re relying on risk adjustment for accurate reimbursement.
Real-World Example: Coding Chronic Systolic Heart Failure
Let’s say you’re reviewing a chart that indicates a patient has chronic systolic heart failure.
What You Shouldn’t Code:
I50.9 – Heart failure, unspecified → No longer maps to HCC under V28
What You Should Code:
I50.22 – Chronic systolic (congestive) heart failure
But that’s not enough on its own! You need clinical validation, like:An echocardiogram showing EF < 40%
Progress notes that mention reduced ejection fraction
Documentation of medications that align with systolic HF management (e.g., beta-blockers, ACE inhibitors)
Clinical Coding Tip: Be Specific, or Be Sorry
CMS isn’t just asking for more — they’re asking for smarter. The new HCC model aims to align documentation with real clinical evidence, not vague assumptions. Here’s how to sharpen your coding lens:
Always Document the Following:
Ejection Fraction (EF) – Include the percentage from the echo
Type – Is it systolic, diastolic, or combined?
Chronicity – Is the patient’s condition acute, chronic, or both?
Clinical Support – Notes from cardiologists, echo reports, radiology findings
Why It Matters: The Stakes Are Higher Than Ever
1. Risk Score Accuracy
Each HCC that gets mapped influences the patient’s risk adjustment factor (RAF), which in turn affects reimbursement for Medicare Advantage plans. Miss out on specific coding, and you’re leaving money on the table.
2. Audit Readiness
Vague documentation is audit bait. If CMS reviews your claims and sees an HCC without supporting evidence, you could face clawbacks, penalties, or worse.
3. Better Patient Care
More accurate documentation also means better communication among care teams. When EF, chronicity, and HF type are clearly spelled out, care plans are better targeted.
Don't Fall for These Common Pitfalls
Here’s where many coders and clinicians slip up under the new model:
Using Unspecified Codes – These no longer support HCCs
Omitting EF Values – You need to quote the EF number (e.g., “EF of 35%”)
Not Differentiating Types – Don’t just say “CHF”; clarify systolic vs. Diastolic
Skipping Chronicity – Acute, chronic, or acute-on-chronic must be stated
Quick Reference: Heart Failure Codes with EF Documentation
When coding heart failure under V28, remember — the details matter. Here are the key ICD-10 codes you should know, along with EF criteria and whether they still map to an HCC.
1. I50.22 – Chronic Systolic (Congestive) Heart Failure
Use when EF is less than 40%
Requires documentation of reduced ejection fraction (HFrEF)
Yes, this maps to an HCC in V28
2. I50.32 – Chronic Diastolic (Congestive) Heart Failure
Use when EF is greater than 50%
Documentation should reflect preserved EF (HFpEF)
Yes, this maps to an HCC in V28
3. I50.23 – Acute on Chronic Systolic Heart Failure
Also used when EF is less than 40%
Be sure to document both the chronic condition and the acute exacerbation
Yes, this maps to an HCC in V28
4. I50.9 – Heart Failure, Unspecified
Avoid this one — it lacks necessary specificity
No EF required, but because of that, it no longer maps to an HCC
Use only when absolutely no additional detail is available (and follow up with provider queries)
Best Practices for Clinicians & Coders
Let’s keep it real — coders can’t pull data from thin air. That’s why collaboration with clinicians is non-negotiable. Here are some strategies that work:
For Providers:
Always include EF when documenting heart failure
State chronicity clearly (acute, chronic, or both)
Note if heart failure is compensated or decompensated
For Coders:
Query providers if EF or type is missing
Look through echo and cardiology reports to support codes
Keep a cheat sheet of EF ranges and code mappings for quick access
FAQs: Heart Failure Coding in V28
Q: Can I still use I50.9 (Heart failure, unspecified)?
A: Technically, yes — but it won’t help your risk score under V28. Always aim for specificity.
Q: What if the EF isn’t documented?
A: Query the provider. If the EF is missing, the code may not support an HCC, which affects RAF scores.
Q: Is it okay to code systolic or diastolic HF without echo data?
A: Not ideal. V28 places a heavy emphasis on clinical validation. If audited, you must show evidence like EF to support the diagnosis.
Q: What EF values correspond to systolic vs. diastolic HF?
Systolic HF: EF < 40%
Diastolic HF: EF > 50%
Mid-range (possible combined): EF 40–50%
Your Action Plan: Precision in Every Pulse
Here’s how to thrive in this new V28 world:
Audit Your Current HF Codes – How many are still using I50.9? Time to upgrade.
Train Clinical Teams – Teach the importance of EF, type, and chronicity.
Set Up Smart Queries – Coders should flag missing EF or ambiguous terms.
Use Templates in EHR – Create structured fields for EF and HF classification.
Review Echo Reports Proactively – Get coders involved earlier in the documentation chain.
Final Thoughts: Coding with Confidence
The move to V28 isn't just a compliance update — it's a call to action. In the case of heart failure, precision = protection + performance. Every documented EF, every properly selected code, and every query answered accurately gets you closer to:
Proper reimbursement
Stronger audit defense
Better care for your patients
So don’t just code for the chart — code for clarity, code for compliance, and code with heart.
Helpful Resources
6. Risk Adjustment Alert: Obesity, Malnutrition & Frailty Now Demand Clinical Validation
Major Coding Shake-Up: Obesity, Malnutrition & Frailty Under the Microscope
In recent updates to risk adjustment guidance, there's a sharp focus on stripping out vague or non-specific codes — especially when it comes to conditions like obesity, malnutrition, and frailty.
Why? Because these conditions can significantly influence risk scores, CMS is making it clear: only diagnoses backed by real clinical data should drive payment.
That means coders, providers, and care teams must now treat these diagnoses with a whole new level of scrutiny.
What’s In vs. What’s Out: Know Your Codes
Here’s where things stand:
✅ Still Valid for HCC Adjustment (with documentation):
E66.01 – Morbid (severe) obesity due to excess calories
E43 – Unspecified severe protein-calorie malnutrition
❌ No Longer HCC-Adjusting:
E66.9 – Obesity, unspecified
R54 – Age-related physical debility (commonly used to describe frailty)
Why the change?
Codes like E66.9 and R54 are too vague. They lack specificity and don't reflect measurable clinical severity. CMS is signaling that if the diagnosis isn’t clearly defined — and supported — it won’t count.
Clinical Coding Tip: Back It Up or Leave It Out
To ensure diagnoses for obesity, malnutrition, or frailty are accepted and risk-adjusted:
Include This in Your Documentation:
BMI values (Body Mass Index): Make sure they are recent and clearly stated
Weight history or trends: Sudden weight loss, persistent underweight conditions
Nutritional assessments: Dietician or nutritionist notes, feeding issues, lab data
Functional status indicators: For frailty, include PT/OT reports or geriatric assessments
These pieces of documentation don’t just validate the code — they build a clinical narrative that tells CMS this is a real, managed condition, not just a checkbox.
Real-World Coding Examples
Let’s bring this to life with a couple of examples:
Correct Way:
Diagnosis: Morbid obesity
Code: E66.01
Documentation: BMI of 42, history of failed weight loss attempts, nutritionist involvement, mobility impact
This is risk-adjustable and audit-defensible.
Incorrect Way:
Diagnosis: Obesity
Code: E66.9
Documentation: No BMI, no detail on severity or impact on health
This no longer maps to an HCC and won’t contribute to your risk score.
Correct Way:
Diagnosis: Severe malnutrition
Code: E43
Documentation: Weight loss >10% in 6 months, poor appetite, dietician notes, low albumin levels
Meets clinical criteria and HCC mapping.
Incorrect Way:
Diagnosis: Debility or Frailty
Code: R54
Documentation: “Appears weak,” or “age-related decline” without functional testing
Not valid for risk adjustment. CMS no longer recognizes this as HCC-qualifying.
Why This Matters for MA Plans & Risk Scores
When documentation lacks specificity, risk scores drop — and payments follow. But the stakes are bigger than just dollars.
Here’s what’s on the line:
Compliance Risk: Unsupported HCCs = audit findings, clawbacks, and headaches
Care Management Accuracy: Risk scores help stratify patients for care programs
Trust in Data: CMS is raising the bar. Plans that adapt will lead, others will scramble
In short, obesity, malnutrition, and frailty are no longer "easy HCC wins". They’re clinical diagnoses — and must be treated that way in the coding and documentation process.
Action Steps for Coders & Providers
Coders:
Stop defaulting to E66.9 or R54
Query for BMI, lab values, or clinical assessments if missing
Flag vague documentation for review before submission
Providers:
Be clear in describing severity and functional impact
Document contributing factors (e.g., appetite, weight change, mobility)
Include nutritionist or therapist notes whenever available
Final Thoughts: Precision Over Assumption
As risk adjustment becomes more targeted, every code must stand on clear clinical legs. If obesity, malnutrition, or frailty are part of your patient population — and they often are — you must start treating them as conditions that require evidence, not assumptions.
This isn’t just a documentation upgrade — it’s a mindset shift.
So, the next time you see “obesity” or “frailty” in a chart, ask:
Is this code specific enough? Can we back it up if we’re audited?
If not — refine it or leave it out.
Need Help Validating Your Risk Adjustment Submissions?
Reach out to sales@healthdatamax.com Or Contact Us Here.
Let’s make your coding smarter, your documentation tighter, and your scores fully defensible.
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7. Infectious Diseases Still Count in Risk Adjustment: TB and Hepatitis C Remain Relevant
As we transition from CMS-HCC V24 to V28, many coding professionals and health plans are closely monitoring what’s in, what’s out, and what still carries weight in risk adjustment. One key takeaway? Infectious diseases like Tuberculosis (TB) and Hepatitis C (Hep C) still count—but the documentation has to be done right.
Yes, TB and Hep C Still Map to HCCs in V28
Even with the introduction of new categories and realigned hierarchies in V28, both Tuberculosis and Hepatitis C remain valid HCC-driving conditions—as long as they are clinically supported and actively managed.
Examples from the V28 model:
Pulmonary mycobacterial infection (A310) → Maps to HCC 6: Opportunistic Infections
Hepatitis C carrier state (Z22.51) → Still counts if there's PCR confirmation and a treatment or monitoring plan
Clinical Coding Tip:
Don’t code these infectious diseases as “history of” unless a current care plan is documented.
A history code without evidence of ongoing treatment, evaluation, or monitoring is insufficient for risk adjustment purposes.
What You Should Do:
Review infectious disease diagnoses carefully before dropping them from claims or EHR exports.
Ensure Z22.51 (Hep C carrier) is accompanied by:
A PCR lab result
A documented treatment plan (e.g., antivirals, specialist referral)
For TB, make sure active or latent infections are supported by:
Chest X-ray or sputum results
Ongoing treatment or surveillance documentation
Why This Matters:
In V28, CMS is more selective—but not dismissive—of conditions that signal chronic infection risk or impact on care complexity. Coding these correctly supports accurate risk scores, care coordination, and compliance.
Final Thought:
Just because a diagnosis is long-standing doesn’t mean it’s inactive. If your providers are still monitoring, treating, or counselling, then you can still code it. But remember: no care plan, no HCC.
Need help auditing your infectious disease codes under V28? Reach out to us at sales@healthdatamax.com for comprehensive Risk Adjustment platform including audit support.
8. Clinical Judgment Still Reigns: Why HCCs Must Reflect Active Condition Management
Beyond the List: CMS Demands Clinical Relevance
Today, CMS expects that each submitted HCC reflects an actively managed condition, not a passive mention or old record. That means you need to show your work — labs, medications, referrals, and progress notes that prove the condition is still relevant, still monitored, and still part of the care plan.
Real Example: Chronic Kidney Disease (CKD)
Let’s break it down with a common example: CKD.
Correct HCC Submission:
Diagnosis: Chronic Kidney Disease
Documentation includes:
Recent lab work (e.g., eGFR or creatinine trends)
Current medication regimen (e.g., ACE inhibitors)
Specialist involvement, such as a nephrology consult
Evidence in the progress note that CKD is being addressed at the visit
This paints a complete, current, and actionable clinical picture.
Incorrect Submission:
Diagnosis listed: CKD
No recent labs, no medication updates, and no mention in provider notes
No indication that the condition is being monitored or treated
This type of submission may trigger audits or get flagged as unsupported — even if the diagnosis is technically accurate.
Clinical Coding Tip: Reaffirm Condition Activity at Every Visit
One of the simplest but most powerful habits to build into your workflow is this:
Use each visit to reaffirm the condition’s activity.
This doesn’t mean you have to do a full workup every time — but you should:
Reference recent labs or imaging
Note ongoing medication use or changes
Mention specialist referrals or prior visits
Describe symptoms or the absence of symptoms with monitoring
A short line in the note like “CKD Stage 3 remains stable, monitored with eGFR every 6 months, managed with lisinopril” can make all the difference.
Why This Matters More Than Ever
Here’s the bigger picture: CMS is actively tightening standards around risk adjustment documentation — especially under increasing RADV audit activity.
Plans and providers that submit codes without supporting evidence risk:
Clawbacks of payments
Failed audits
Compliance flags
Loss of trust in data integrity
But plans that show active, ongoing management not only protect their risk scores — they also ensure that patients are getting the level of care their conditions require.
How Coders and Providers Can Work Together
For Coders:
Don’t just look for a code — look for proof.
Query providers when documentation doesn’t reflect active care.
Educate your teams on the difference between “on the list” and “being managed.”
For Providers:
Be specific in your progress notes.
Avoid copying forward old diagnoses without current context.
Include actionable phrases like “monitored,” “managed,” or “treated.”
Final Thoughts: The Human Side of Coding
Risk adjustment is a data-driven model — but it depends on real, ongoing care.
At the heart of it is clinical judgment, the provider's decision to monitor, treat, or refer based on the patient’s needs today — not just what was on the chart last year.
So the next time you document a chronic condition, ask:
“Is this diagnosis still active, and have I shown that in the note?”
If yes, your coding will stand strong. If not, it’s time for a quick update — for the sake of compliance, care, and accuracy.
Need help aligning your clinical documentation with HCC coding best practices? Reach out to sales@healthdatamax.com or visit healthdatamax.com to connect with our team.