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 

  1. 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.

  2. Payment HCCs Expanded

    • V24 had 86 payment HCC categories.

    • V28 expands this to 115, allowing for more nuanced representation of patient conditions and risk.

  3. 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.

  4. 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: 

  1. Update internal HCC crosswalks to reflect V28 mappings. 

  2. Educate providers and coders about the loss of MDD/anxiety from the risk model. 

  3. Audit documentation to identify patients who may qualify under neurocognitive HCCs instead. 

  4. Enhance training on recognizing and documenting G30.x and F01.x codes properly. 

  5. 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 wanna 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