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