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