Healthcare reimbursement is evolving, and the CMS-HCC Model V28, planned for implementation in 2026, introduces major changes that affect how patient conditions are documented and how providers generate revenue.
For organizations participating in Medicare Advantage, these updates are no longer optional to understand. The new model improves the classification of chronic conditions, adds new hierarchies of codes, and modifies the risk scores calculation.
Those providers who plan will be at an advantage. Organizations that delay preparation risk losing revenue and creating documentation gaps that directly impact financial performance. This transformation needs strategic planning, employee education, and technology that facilitates proper clinical documentation. Below is a breakdown of what is changing, why it matters, and how organizations can prepare.
What is the CMS-HCC Model?
The CMS Hierarchical Condition Category (HCC) model determines Medicare Advantage payments by predicting healthcare costs based on patient diagnoses. The Centers for Medicare & Medicaid Services uses this model to adjust payments fairly across different patient populations.
Here’s how it works:
- Health plans receive higher payments for patients with more severe or multiple chronic conditions
- Diagnosis codes from patient encounters generate HCC categories
- Each HCC category carries a specific risk adjustment factor
- These factors combine to create a patient’s overall risk score
The model ensures that plans caring for sicker patients receive appropriate compensation. Version 28 represents the most comprehensive update to this system in years, affecting thousands of diagnosis codes and their associated risk weights.
Key Changes in CMS-HCC Model V28
CMS-HCC Model V28 introduces several significant changes that affect how patient conditions are documented and coded. The modifications will impact mappings of diagnosis codes, risk weights, and clinical documentation requirements among Medicare Advantage populations. Understanding these changes allows organizations to plan effectively and protect appropriate reimbursement.
Updated Disease Hierarchies
The new model restructures how related conditions interact within hierarchies. Some conditions that previously suppressed others now stand independently, while new hierarchical relationships have been established.
Major hierarchy changes:
- Diabetes classifications: Separate categories for complications
- Kidney disease stages: More granular staging requirements
- Mental health conditions: Expanded categories for behavioral health
- Cardiovascular disease: Refined classification of heart conditions
These changes mean providers must document with greater specificity. A general diagnosis of diabetes without complication details may not capture the full risk score under V28 risk adjustment.
Diagnosis Code Mapping Updates
Thousands of ICD-10 codes have been remapped to different HCC categories or removed entirely. Some codes that generated risk scores under V24 won’t carry the same weight in V28.
What this means for documentation:
- Review current diagnosis patterns across your patient panel
- Identify codes that will map differently under V28
- Train clinical staff on new documentation standards
- Implement tools that flag potential coding gaps
The remapping reflects updated clinical understanding of disease progression and severity. Providers who continue documenting as they did under V24 will likely see reduced risk scores and lower reimbursement.
Risk Weight Adjustments
Risk adjustment factors have been recalibrated to reflect current healthcare spending and utilization patterns. Some conditions now carry higher risk weights, while others have been reduced. Learning about these weight changes will also guide documentation activities and concentrate on the correct recording of conditions with a high risk adjustment influence.
Why V28 Matters for Healthcare Providers
The transition to CMS HCC V28 directly affects revenue, documentation standards, and operational workflows for Medicare Advantage organizations. Providers who underestimate the scope of these changes risk financial losses and compliance issues. The model shift requires fundamental changes in how clinical teams approach patient documentation and how organizations coordinate between clinical and administrative functions.
Financial Impact on Medicare Advantage Plans
Payment accuracy depends on complete and precise clinical documentation. When providers miss documenting eligible conditions or lack specificity, risk scores drop. Lower risk scores mean reduced capitation payments from CMS.
Revenue considerations:
- Incomplete documentation leads to underpayment
- Missing annual diagnoses removes conditions from risk calculations
- Lack of specificity results in lower-weighted HCC assignments
- Poor coordination between clinical and coding teams creates gaps
Organizations should calculate their potential financial exposure under V28. Analyze current documentation patterns against new requirements to identify revenue at risk.
Documentation Requirements Become Stricter
V28 raises the bar for clinical documentation. Vague statements or incomplete condition descriptions won’t support risk adjustment claims. Each diagnosis must be supported by clinical evidence in the medical record.
Documentation must now include:
- Specific disease stages and severity levels
- Current treatment and management plans
- Patient response to interventions
- Complications and comorbidities
Providers need to document every relevant chronic condition at least annually. One-time documentation doesn’t carry forward. If a condition isn’t recorded during a payment year, it doesn’t contribute to that year’s risk score.
Clinical and Coding Alignment
The gap between clinical documentation and coding requirements becomes more apparent under V28. Physicians focus on patient care while coders extract billable diagnoses. This disconnect leads to revenue leakage. Effective organizations reduce this gap through regular clinician–coder feedback, targeted provider education, real-time documentation guidance at the point of care, and systems that clearly surface coding opportunities.
How to Prepare for V28 Implementation
Successful V28 transition requires planning well ahead of the 2026 implementation timeline. Organizations need a comprehensive approach that includes staff training, workflow redesign, technology adoption, and ongoing performance monitoring. Planning gives time to experiment with strategies, optimize the processes, and develop organizational preparedness in all those departments that would participate in risk adjustment.
Build a Structured Transition Plan
Companies require detailed planning measures for the 2026 implementation. Delaying until late 2025 is not much time to train the staff and update the system.
Essential preparation steps:
- Assess current state: Analyze existing documentation patterns and identify gaps
- Develop training programs: Create role-specific education for clinicians, coders, and administrative staff
- Update workflows: Redesign documentation processes to support V28 requirements
- Test systems: Run parallel processing with V24 and V28 to understand the impact
- Monitor progress: Establish metrics tracking readiness across the organization
Begin with a baseline review of the present documentation and compare it with V28 standards. This exposes certain spheres that need to be addressed and allows prioritizing the resources.
Invest in Staff Education
Provider education makes the biggest difference in successful V28 adoption. Clinicians need to understand what changed and why it matters to their patients and organization.
Training should cover:
- Specific HCC categories relevant to your patient population
- Documentation language that supports accurate coding
- Common documentation pitfalls and how to avoid them
- Real examples from your organization’s patient encounters
Make training practical and relevant. Use actual patient cases from your practice to demonstrate documentation improvements.
Leverage Technology Solutions
Manual tracking of HCC opportunities across thousands of patients isn’t sustainable. Technology platforms help identify documentation gaps and guide providers toward complete, specific documentation. Digital health platform capabilities that support V28 preparation include automated identification of HCC opportunities from patient records, real-time documentation prompts at the point of care, comparison of V24 and V28 risk scores for each patient, and analytics showing documentation trends across providers.
Common Challenges in V28 Transition
Organizations face significant operational challenges when preparing for V28 risk adjustment implementation. These challenges stem from fragmented technology environments, resistance to workflow changes, and complex cross-department coordination. Early identification of these challenges helps organizations to formulate specific solutions to the challenges, which consider the underlying causes other than the symptoms.
Managing Multi-Vendor Technology Environments
Healthcare organizations normally have a lot of software systems that lack effective communication. Practice management systems, electronic health records, coding platforms, and analytics tools tend to exist in silos.
This fragmentation creates serious challenges:
- Patient data is scattered across disconnected systems
- Manual processes for transferring information between platforms
- Inconsistent data quality and completeness
- Delayed access to critical clinical information
Organizations managing up to 30 different steps from provider documentation to CMS submission face enormous coordination complexity. Each handoff introduces potential for error or information loss.
Ensuring Data Interoperability
Patient information needs to flow seamlessly between systems. When a provider updates a diagnosis or treatment plan, that change should propagate to all relevant platforms automatically.
Interoperability requirements include:
- Bidirectional data exchange between clinical and administrative systems
- Standardized data formats for consistent interpretation
- Real-time synchronization to maintain current information
- Audit trails showing data movement and modifications
Organizations should map their data flows to identify bottlenecks and gaps. Document how patient information moves from clinical encounter through coding, billing, and reporting.
Addressing Provider Resistance
Physicians and clinical staff face constant pressure to adopt new processes and technologies. V28 represents another significant change requiring their attention and adjustment. Overcome resistance through transparent communication about why these changes matter. Show providers how improved documentation benefits their patients through better care coordination and resource allocation.
Best Practices for V28 Success
Effective V28 implementation depends on provider-centric strategies that align with existing clinical workflows. Companies that value transparency, constant improvement, and cross-functional teamwork attain higher performance. These practices minimize disruption, improve documentation quality, and help maintain provider engagement during the transition.
Focus on Provider-Centric Solutions
Implementations of technology are effective when they facilitate provider workflow and do not interfere with it. The tools must blend with the existing processes and demand minimal extra steps.
Provider-friendly features include:
- Embedded guidance within electronic health record workflows
- One-click acceptance of suggested documentation additions
- Visual indicators showing completeness of patient risk profile
- Minimal clicks required to document conditions properly
Providers should feel empowered rather than monitored. Systems that highlight opportunities without mandating specific actions preserve clinical autonomy while improving documentation.
Implement Transparent AI Systems
Artificial intelligence and natural language processing help identify HCC opportunities from clinical notes. However, providers must understand and trust these suggestions. Transparent systems show the source data behind each recommendation, explain the clinical logic linking patient findings to HCC opportunities, allow providers to accept, modify, or reject suggestions, and clearly display the impact on risk scores.
Create Cross-Functional Teams
Successful V28 transition requires coordination across clinical, coding, billing, and administrative departments. Siloed approaches create gaps and inconsistencies.
Build teams that include:
- Practicing physicians and advanced practice providers
- Certified professional coders with HCC expertise
- Clinical documentation improvement specialists
- Revenue cycle management staff
- Health information technology personnel
Regular meetings keep everyone aligned on goals, progress, and emerging challenges.
Final Insights
CMS-HCC Model V28 represents a fundamental shift in how Medicare Advantage risk adjustment works. Providers who prepare strategically can protect revenue while improving documentation accuracy. Organizations that delay preparation face financial risk and operational disruption when implementation begins in 2026. At this point, turn attention to education, technology, and process improvement that will place your organization into success under the new model.
Persivia delivers V28-ready risk adjustment solutions that unify clinical data from EHRs, claims, labs, and more into a single patient view. CareSpace® uses advanced natural language processing to surface HCC opportunities directly within provider workflows while displaying both V24 and V28 insights for smoother transition planning.
