A Deep Dive into the CMS-HCC V28 Model

Understanding the Shift to V28

The Centers for Medicare & Medicaid Services (CMS) have finalized the transition to the CMS-HCC Version 28 model, a move that will fundamentally alter how risk scores are calculated for Medicare Advantage plans. This update, phasing in over three years starting in 2024, is one of the most significant revisions to the model in years.

Key Changes in the V28 Model

1. Clinical Reclassification: The model is updated based on more recent Medicare fee-for-service data (from 2018 diagnoses and 2019 costs), reflecting more current medical practices and costs.
2. Removal of Codes: Over 2,000 diagnosis codes have been removed from the payment model. Many of these are for conditions CMS now considers less specific or less predictive of future healthcare costs. This makes avoiding common mistakes, like using outdated or deleted codes, more critical than ever.
3. Constraint Application: The V28 model applies "constraints" to certain HCCs, particularly those related to diabetes, congestive heart failure, and COPD. This means that the presence of a more severe condition will suppress the risk score contribution of a less severe, related condition. For example, a patient with both Diabetes with and without complications will only have the risk score for the more severe diagnosis (with complications) applied.

The Impact on RAF Scores and Revenue

The primary impact for healthcare organizations will be a potential decrease in Risk Adjustment Factor (RAF) scores. CMS itself projects a -3.12% change in risk scores due to the model update. This is largely driven by:

• The removal of previously payable diagnosis codes.
• The new constraining logic, which prevents "stacking" of related diagnoses.
• Increased reliance on highly specific and well-documented codes. This increased reliance means that the ability to extract specific diagnoses from unstructured data is no longer a luxury, but a necessity.

Organizations that have not proactively prepared for this shift may see a significant negative impact on their revenue stream from Medicare Advantage plans.

How MedChartScan Helps You Prepare for V28

Surviving and thriving under V28 requires a new level of precision in clinical documentation and coding. This is where AI-powered platforms like MedChartScan become essential tools for your team.

• Comprehensive Code Detection: Our clinically-trained LLM analyzes all patient data—including unstructured notes, faxes, and lab reports—to surface every potential HCC, helping your team find newly critical specific codes.
• V28 Logic-Enabled: The MedChartScan platform is fully updated with the V28 model's logic, including all constraints. It automatically flags less specific codes when a more severe, constraining diagnosis is present, helping your coders submit the most accurate and compliant data. See how this clinical intelligence supports the coding workflow.
• Improved Coder Efficiency: By automating the initial review and flagging the most relevant information, MedChartScan allows your coding team to focus on validation and complex cases, boosting productivity and supporting a smooth transition to the new model.

*Want to see exactly how our V28 logic engine can protect your RAF scores? Schedule a personalized demo and see it in action._

The move to V28 is a challenge, but it's also an opportunity to refine your risk adjustment processes. By leveraging advanced AI to support your team, you can enhance coding accuracy, protect your revenue, and stay ahead of the curve.