As Medicare Advantage organizations adapt to the CMS-HCC Version 28 risk adjustment model, key changes are reshaping how chronic conditions—particularly metastatic cancers—affect risk scores and payment accuracy. One of the most notable updates in V28 is the enhanced emphasis on specificity and clinical alignment, especially when it comes to cancer coding.

1. What’s New Under V28?

Greater emphasis on metastatic cancers: The new model assigns a higher weight to diagnoses reflecting both primary and secondary malignancies.
Refined HCC mappings: Conditions are grouped in a way that better mirrors actual disease severity and patient complexity.
Reduced tolerance for vague documentation: Using generic or unspecified codes may no longer be enough to qualify for risk adjustment—clinical specificity is now essential.

2. RAF Comparison: What It Means for You

Let’s take a typical coding example involving both a primary lung malignancy and a secondary brain metastasis. Under the previous model, this combination contributed significantly to a member’s risk score. Under V28, the same coding leads to even greater risk recognition.

What’s the impact?

The updated model rewards thorough and specific documentation of metastatic conditions.
Even without changing the patient’s health status, the risk adjustment compensation improves under V28.
The improvement reflects CMS’s push toward more clinically accurate coding that aligns with real-world disease progression.

3. Why This Matters for Risk Adjustment

Improved reimbursement accuracy: Health plans that ensure precise documentation and coding can receive more appropriate capitation payments.
Coding precision is no longer optional: CMS has removed many unspecified cancer codes from risk adjustment eligibility. For example, lung cancer must now include laterality and site specificity to be counted.
Clinical alignment drives value: The new model prioritizes diagnoses that reflect a comprehensive view of disease burden and treatment intent.

4. Clinical Coding Tip

To capture the full risk adjustment value under V28:

Ensure both primary and secondary cancer sites are explicitly documented.
Record staging, biopsy findings, and treatment goals in the medical record.
Link the diagnosis to supporting clinical evidence—like imaging, consults, and progress notes.

Example Documentation:
“Patient diagnosed with right lung carcinoma confirmed via biopsy, with evidence of metastasis to the brain. Currently undergoing palliative chemotherapy.”

5. Operational Takeaways

Review and update older cancer diagnoses to ensure they conform with V28 logic.
Educate providers on the importance of site-specific cancer coding.
Use technology to detect and address under-coded metastatic conditions across charts and claims.

How Health Data Max Can Help

Our AI-enabled Risk Adjustment Platform supports your V28 transition by:

Automatically identifying vague or unspecified cancer codes.
Validating provider documentation against clinical coding rules.
Recommending accurate and compliant HCC assignments.
Modelling the impact of proper coding on overall risk scores.

Let us help you maximize compliant documentation and minimize missed opportunity under V28.

Reach out at: sales@healthdatamax.com or you can visit www.healthdatamax.com