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.