The expectations around Risk Adjustment HCC Coding are changing fast, and healthcare organizations that rely on risk-adjusted revenue need to pay close attention. The transition to CMS HCC V28 isn’t just a model update—it’s a signal. CMS is doubling down on specificity, clinical validity, and audit transparency. For providers, payers, and risk-bearing entities, the shift from CMS HCC V24 to V28 brings a clear message: coding must be precise, documentation must be defensible, and teams must be audit-ready at all times.
What Makes V28 So Different?
CMS HCC V28 introduces significant changes that reshape how risk is captured and reported. Several HCC categories have been removed or merged, making it more difficult to code certain chronic conditions that previously contributed to risk adjustment. This means teams can no longer rely on familiar codes that once carried weight; many have been downgraded or excluded entirely.
Alongside these structural changes, V28 tightens the expectations around documentation. Simply referencing a diagnosis is no longer enough. Each code must be supported with clinically credible evidence that meets MEAT (Monitoring, Evaluation, Assessment, and Treatment) criteria. The emphasis has shifted from quantity of codes to quality of supporting detail.
This increased scrutiny drives greater volatility in RAF scores, particularly for organizations still relying on outdated workflows. Without clear documentation tied directly to patient encounters, codes are more likely to be disallowed, reducing both reimbursement and the accuracy of the patient’s risk profile.
RADV Audits Are Tightening in Parallel
While V28 raises the documentation bar, CMS is simultaneously increasing the pressure through RADV audits. These audits are becoming more comprehensive, aggressive, and financially consequential.
One of the most impactful changes is the use of extrapolation. If a single unsupported code is identified in an audit sample, CMS may apply that error rate across an entire population—leading to significant repayments. This means even minor documentation lapses can create major financial liabilities.
Additionally, CMS now demands ironclad chart integrity. A diagnosis not clearly supported in the chart is immediately disqualified. There is no leeway for generalizations or vague references. Chart production timelines have also shortened, and organizations must respond quickly to audit requests, leaving little time for cleanup or clarification.
The cumulative effect is a tighter, more unforgiving audit environment. Coding must be exact, documentation must be clear, and compliance strategies must be embedded into daily workflows—not activated after an audit letter arrives.
Forward-Looking Risk Adjustment Strategies for Compliance and Resilience
To meet these new demands, healthcare leaders must adopt more proactive, technology-supported, and provider-aligned risk adjustment practices.
- Tighten Documentation Standards Now
Waiting for V28 to be fully enforced is a risk. The time to improve documentation quality is now. Begin by reviewing current coding and documentation habits for compliance with V28 logic. Ensure that coders and clinicians are capturing specificity, using accurate terminology, and including MEAT-backed clinical justifications in every note.
- Train and Re-Train Providers
Model transitions like V28 introduce nuances that even seasoned providers can miss. Invest in regular, focused training to ensure clinicians understand the importance of documenting exclusions, clarifying chronic conditions, and differentiating between related diagnoses. When providers understand what drives risk scores and audit defensibility, their documentation improves naturally.
- Build Concurrent Coding Capacity
One of the most powerful strategies for compliance is concurrent coding—real-time documentation review and support during or immediately after patient visits. This approach reduces the risk of retroactive errors and ensures each chart is coded accurately before submission. It also helps reduce administrative burden and provider frustration by resolving documentation gaps when the clinical details are still fresh.
- Use Audit Simulations to Pressure-Test Charts
Before CMS pulls your records, do it yourself. Internal RADV mock audits help uncover high-risk patterns, documentation gaps, and recurring code weaknesses. Focus on populations and diagnoses that are most affected by the V28 update, and use these findings to guide education, workflow improvements, and policy updates.
- Partner with Strategic Technology Vendors
Technology that understands V28, provides real-time feedback, and integrates directly with EHR systems is no longer optional. Platforms that offer AI-powered chart reviews, risk capture suggestions, and compliance alerts can drastically reduce audit exposure. These solutions act as a second set of eyes—catching what manual processes miss and scaling compliance efforts across your organization.
What Success Looks Like in the V28 and RADV Era
In the new era of risk adjustment, success isn’t about capturing the most codes—it’s about capturing the right ones, for the right reasons, backed by defensible documentation.
That means building medical records that fully reflect the complexity of patient conditions, aligning coding and CDI teams on unified quality goals, and ensuring RAF scores are a true reflection of patient acuity.
Organizations prepared for V28 won’t just pass audits—they’ll thrive in value-based care environments by linking documentation quality to financial integrity and patient outcomes. Their providers will feel supported, not burdened. Their coding will be accurate, not inflated. And their compliance posture will be proactive, not reactive.
Common Mistakes That Need Immediate Attention
Some organizations may assume that simply updating their HCC software is enough. But relying on legacy V24 mapping tools undercuts accuracy. Others may overlook the educational gap between what providers know and what V28 requires—leading to documentation that misses the mark even when intent is correct.
Retrospective reviews still have their place, but waiting until year-end to catch documentation gaps is a costly gamble. By then, the opportunity to document many chronic conditions has already passed.
Another mistake is failing to recognize how subtle documentation changes can significantly impact risk scores and audit exposure. For example, a lack of MEAT detail can lead to code disqualification—even if the diagnosis is technically present.
Closing the Gap with V28 Preparedness
The future of Risk Adjustment HCC Coding is moving toward transparency, accountability, and accuracy—and V28 makes that shift official. Organizations that wait to adapt will find themselves behind, vulnerable, and scrambling to respond when CMS knocks. But those who act now, align their workflows, and strengthen their documentation practices can meet the demands of CMS HCC V24 to V28 head-on—with confidence, clarity, and control.
