The shift from HCC Model V24 to V28 may reduce risk-adjusted payments and create financial challenges for Medicare Advantage plans. CMS removed 2,294 ICD-10 codes that previously mapped to HCCs, meaning these codes no longer contribute to risk scores under V28. The outcome is an estimated 3.12% payment reduction, which equals a system-wide savings of $ 11 billion. For individual organizations, this implies that revenues will decrease unless they change their coding and documentation practices in the near future.
This difficulty is addressed by technology platforms that automate the difficult transition. Providers receive real-time financial impact analysis and instant comparisons instead of having to manually monitor two versions of a model and compute blended RAF scores. The appropriate platform will transform regulatory complexity into simplified functions, safeguarding revenue, and ensuring coding accuracy during the three-year phase-in period.
What Changed Between V24 and V28?
The new risk adjustment model fundamentally reshapes how Medicare calculates patient risk scores. V28 removes thousands of diagnosis codes and changes payment weights across multiple condition categories.
Major Model Differences
V28 eliminates 2,294 ICD-10 codes that previously mapped to HCCs. Conditions not captured through remaining valid codes no longer contribute to risk scores. In some common condition categories, related HCC coefficients are constrained to share similar values, reducing differences in risk contribution.
Key changes include:
- Some payment rules under V28 modify how multiple conditions interact in risk scoring, which can increase RAF for complex patients.
- Higher coefficients for immunity disorders and chronic ulcers
- Lower RAF scores for simple cases like isolated diabetes
- Significantly higher scores for complex, multi-condition patients
How Technology Platforms Handle The Transition
Manual management of the model transition increases the risk of documentation gaps and missed scoring opportunities. Organizations managing thousands of patients cannot realistically compare model versions for each case without automation.
Automated Code Validation
Platforms validate every diagnosis code against both V24 and V28 mappings automatically. The system identifies codes that no longer contribute to HCCs and suggests valid alternatives based on clinical documentation.
This automation provides:
- Real-time alerts when providers select removed codes
- Alternative code suggestions to optimize valid HCC capture
- Side-by-side comparison of V24 versus V28 impacts
- Instant RAF scores calculation under both models
Organizations see the financial difference before submitting claims, allowing them to improve documentation while patients are still in active treatment.
Blended Calculation Management
The three-year transition requires different percentage blends each year. In 2024, calculations use 67% V28 and 33% V24. Technology platforms automatically apply the correct weighting based on service dates. By 2025, when V28 is fully applied to dates of service, organizations should have workflows adapted to the new risk calculations.
Which High-Value HCCs Should Organizations Target?
V28 significantly increases coefficients for specific condition categories. Platforms identify these opportunities within existing patient populations, helping organizations maximize legitimate reimbursement.
Priority Conditions Under V28
Notable conditions with higher relative values under V28 include chronic ulcers, advanced heart failure categories, specific pulmonary fibrosis groups, and late-stage kidney disease. Technology platforms scan patient records against these categories and flag documentation opportunities at the point of care.
Real-time identification delivers:
- Alerts for high-value HCC opportunities during patient visits
- Documentation templates supporting proper code capture
- Clinical decision support guiding appropriate diagnosis selection
- Financial impact calculations showing revenue differences
What Documentation Standards Does V28 Require?
V28 requires more precise documentation because fewer codes contribute, and risk scores rely on severity and specificity. With fewer valid ICD-10 codes available, providers must capture conditions through remaining mappings with greater precision.
Essential Documentation Practices
Platforms with clinical decision support guide providers toward compliant documentation in real time. AI-powered systems analyze physician notes using natural language processing, identifying documented conditions that might otherwise go uncoded.
The technology scans clinical narratives, compares findings against historical records, flags potential HCC opportunities, and validates all codes against current V28 mappings. Effective documentation requires specifying condition severity with detailed ICD-10 codes, documenting all chronic conditions at each encounter, and maintaining updated problem lists reflecting current patient status.
How Do Platforms Protect Revenue During Transition?
Changes from V24 to V28 may increase payments for some complex patients while reducing scores for patients with conditions now constrained or removed. Organizations with high percentages of simple diabetes or heart failure cases face payment decreases, while those managing complex, multi-condition patients may see increases.
Revenue Optimization Strategies
Technology platforms identify which patients fall into advantageous categories under V28. The system prioritizes high-value HCCs during encounters, captures all qualifying conditions through comprehensive documentation prompts, monitors RAF score trends across populations, and alerts providers to documentation gaps before claim periods close.
A digital health platform is an amalgamation of clinical records, claims history, social determinants of health, lab results, and pharmacy records. This is a comprehensive perspective that does not leave out anything related to the level of conditions that are present or risk scores.
Takeaway
Successfully transitioning from HCC Model V24 to V28 requires technology that automates code validation, calculates RAF scores in real time, and identifies documentation opportunities before claims close. With CMS projecting $11 billion in system-wide payment reductions, every properly captured HCC directly impacts organizational revenue. Healthcare organizations that adopt comprehensive platforms protect their financial performance while improving coding accuracy throughout the transition period.
Transform Your V28 Adoption with Persivia
Persivia offers CareSpace®, an AI-driven platform integrating V28 changes directly into clinical workflows. The system aggregates data from clinical, claims, and SDOH sources, building comprehensive longitudinal patient records that reveal complete risk profiles. CareTrak® delivers real-time insights at the point of care, allowing providers to review V24 and V28 codes side by side while analyzing RAF score impacts instantly. With 15 years of healthcare expertise, Persivia transforms the V28 transition from regulatory burden into a revenue optimization opportunity.