Building a V28-Compliant Coding Audit and Claims Pricing Program for 2025

As the Centers for Medicare & Medicaid Services (CMS) rolls out the V28 HCC risk adjustment model for 2025, healthcare providers and payers alike must quickly adapt their coding audit strategies. With thousands of ICD-10 codes now retired, clinical documentation rules tightened, and encounter data assuming greater prominence, coding accuracy has never been more critical.

A robust, V28-compliant coding audit program not only ensures compliance but also safeguards revenue integrity in an increasingly value-based reimbursement environment. This guide walks you through building an effective audit program tailored to the V28 framework.

❗ Why You Need a V28-Compliant Audit Program

CMS's V28 model introduces significant changes:

• 2,000+ ICD-10 codes removed from HCC mappings

• New condition categories added

• Greater reliance on encounter data vs. RAPS

• MEAT (Monitor, Evaluate, Assess, Treat) documentation standards emphasized

  
  

Failure to adapt to these changes can result in:

• Risk score underreporting

• Revenue leakage

• Non-compliance penalties

• Poor audit outcomes (e.g., RADV audits)

  
  

An audit program aligned with V28 mitigates these risks by proactively identifying documentation and coding gaps.

🛠️ Step 1: Establish Your V28 Coding Governance Team

Start by assembling a dedicated compliance and coding oversight team:

• Compliance Officer or Director

• Certified Professional Coder (CPC) or Certified Risk Adjustment Coder (CRC)

• Clinical Documentation Improvement (CDI) Specialist

• HIM Director or Medical Billing Manager
  

This task force will:

• Define V28-compliant audit objectives

• Review policy changes and CMS guidelines

• Assign roles and ensure accountability
  

📊 Step 2: Conduct a Baseline Risk Exposure Assessment

Before rolling out audits, determine your current exposure:

• Analyze past HCC submissions

• Identify codes now retired under V28

• Map lost revenue from declassified codes

• Identify top chronic conditions documented
  

Use this data to target areas for improvement, training, and process updates.

📝 Step 3: Update Coding and Documentation Policies

Align your internal protocols with the V28 model:

• Replace outdated ICD-10 code references

• Re-emphasize specificity for HCC-relevant conditions (e.g., CKD Stage 3 vs. unspecified)

• Mandate MEAT documentation on every patient problem list

• Integrate V28 definitions into your EHR prompts
  

Work closely with your legal and compliance teams to validate updates.

📅 Step 4: Build a V28-Aware Audit Plan

Design a quarterly audit calendar that addresses:

• High-risk coding areas (e.g., diabetes, COPD, CHF)

• Encounters from high-volume providers

• Retrospective chart reviews

• Real-time encounter monitoring (prospective audits)
  

Ensure your plan includes both:

• Quantitative reviews (e.g., error rates, HCC capture)

• Qualitative reviews (e.g., MEAT sufficiency, progress note clarity)
  

🎓 Step 5: Train Clinical Staff and Coders

A common audit pitfall is untrained teams. Launch targeted education initiatives:

• Host webinars explaining V28 and key changes

• Distribute coding quick-reference sheets

• Conduct real-time documentation reviews with clinicians

• Offer refresher courses on the MEAT criteria
  

Include physician champions in peer-led training to boost adoption.

🔍 Step 6: Conduct Audits Using V28 Logic

Once policies and training are in place, begin auditing under V28 standards:

• Sample minimum 10% of risk-bearing encounters monthly

• Review both coding and supporting documentation

• Flag codes that no longer map to HCCs under V28

• Validate EHR-generated diagnoses for documentation sufficiency
  

Use tools like risk adjustment software and AI-enhanced coding platforms to streamline audit workflows.

📈 Step 7: Report Findings and Drive Continuous Improvement

Post-audit, consolidate insights into actionable steps:

• Share individual feedback with clinicians and coders

• Report aggregate trends to leadership

• Adjust training programs based on findings

• Refine audit scope quarterly
  

Consider establishing audit scorecards and dashboards to track improvements in:

• Coding accuracy

• HCC recapture rate

• Documentation completeness
  

📅 Step 8: Stay Current with CMS Updates

CMS policy is evolving. Subscribe to:

• CMS Transmittals and MLN Matters newsletters

• ICD-10-CM updates

• HHS Office of Inspector General (OIG) audit findings
  

Attend quarterly payer meetings and risk adjustment summits to remain proactive.

🔚 Final Thoughts

Building a V28-compliant audit program in 2025 is no longer optional—it’s foundational to sustainable, value-based care. With heightened scrutiny on risk capture, encounter validity, and coding accuracy, the stakes are higher than ever.

By following the steps outlined above, healthcare organizations can ensure compliance, strengthen reimbursement accuracy, and cultivate a culture of continuous quality improvement. Now is the time to prepare, educate, and execute. Build Your V28 Audit Program Now! Contact Us Today!