How the V28 HCC Model Reshapes Risk Capture and Claims Pricing for Primary Care Providers

The Centers for Medicare & Medicaid Services (CMS) has begun implementing the Version 28 (V28) Hierarchical Condition Category (HCC) model as part of its ongoing refinement of the Medicare Advantage (MA) risk adjustment methodology. For primary care providers (PCPs), this update represents more than a technical coding change—it shifts how patient complexity is captured and reimbursed.

This blog will explore what the V28 model entails, how it differs from the previous version (V24), and what it means for documentation, coding, and patient engagement strategies in primary care.

📊 What is the V28 HCC Model?

The Hierarchical Condition Category (HCC) model is a risk adjustment methodology used by CMS to calculate expected healthcare costs for Medicare Advantage enrollees. It assigns risk scores to patients based on documented diagnoses, which in turn determine payments to Medicare Advantage Organizations (MAOs).

V28 is phased in from 2024 to 2026:

• 2024: 33% V28 / 67% V24

• 2025: 67% V28 / 33% V24

• 2026: 100% V28

  
  

V28 introduces significant updates:

• Redefined HCC groupings

• Improved clinical accuracy

• Removal of non-specific or potentially upcoded diagnoses

• Alignment with ICD-10 and modern clinical practice

  
  

🔑 Key Changes in V28 Compared to V24

1. More Clinically Precise Groupings

CMS worked with clinical experts to better align HCCs with ICD-10 categories. V28 consolidates overlapping codes and introduces new HCCs for better chronic disease recognition.

• Example: In V24, some diabetes and renal failure codes were dispersed across categories. V28 unifies them under clearer, more clinically relevant HCCs.

  
  

2. Reduced Payment for Low-Value Diagnoses

CMS eliminated several diagnoses from risk adjustment that were either overused or lacked predictive value. These include non-specific pain codes, minor psychiatric conditions, and vague symptom codes.

• Impact: PCPs must shift focus from volume of diagnoses to specificity and clinical validity.

  
  

3. De-emphasis on "coding intensity"”

V28 is designed to resist artificial inflation of risk scores. CMS aims to reduce variation in coding practices and emphasize consistent documentation of true patient complexity.

🩺 Implications for Primary Care Providers

The transition to V28 has deep consequences for primary care practices that often serve as the first and most frequent point of contact in patient care. Here’s how it changes their workflow and strategy:

1. Greater Emphasis on Chronic Condition Management

Primary care providers are now expected to document chronic conditions with greater precision.

This includes:

• Capturing severity levels (e.g., Type 2 Diabetes with CKD Stage 3)

• Documenting all active conditions annually

• Including specificity in both clinical notes and coding

  
  

Why it matters: Chronic diseases such as COPD, diabetes, and heart failure drive risk scores and MAO payments. Inaccurate documentation leads to under-coding and lost revenue.

2. Stronger Role in Revenue Integrity

Because MA payments are tied to risk scores, PCPs have a direct impact on plan revenue. A missed diagnosis code can translate to thousands of dollars in lost payments.

• Tip: Conduct monthly chart audits and reconciliation with coders

• Best Practice: Use HCC coding checklists within your EMR

  
  

3. Improved Data Accuracy = Better Risk Capture

CMS is eliminating RAPS data in 2026, moving to 100% encounter data. Providers must ensure their encounters include clean, structured diagnosis codes that make it to CMS.

• No more safety net from plan-submitted RAPS files

• Encounter data must reflect visit documentation 1:1

  
  

📋 Examples of High-Risk Conditions in V28

Condition	ICD-10 Code(s)	HCC Category in V28
Diabetes w/ Chronic Complications	E11.22, E11.29	HCC 19
Chronic Kidney Disease (Stage 3-5)	N18.3-N18.5	HCC 134
Heart Failure	I50.x	HCC 85
COPD	J44.x	HCC 111
Major Depression	F33.x	HCC 59

🚀 Action Plan for Primary Care Practices

To align with the V28 HCC model, PCPs should:

1. Educate clinicians and coding teams on the new HCCs.

2. Upgrade EHR templates to reflect V28 logic.

3. Create a risk capture checklist for annual wellness visits.

4. Schedule risk review meetings with RCM or billing teams.

5. Collaborate with MA plans to improve documentation workflows.
   

🔍 Real-World Risk Capture Scenario Pre-V28:

• Patient A has Type 2 diabetes, CKD stage 3, and neuropathy.

• Documentation included only E11.9 (Diabetes without complications).

• Risk score impact = low; payment = undervalued

  
  

With V28 Awareness:

• Documentation specifies E11.22 (Diabetes with CKD) and N18.3 (CKD Stage 3)

• Captures HCCs 19 and 134

• Risk score impact = high; payment = accurate

  
  

This illustrates how precise documentation transforms financial and clinical outcomes.

💭 Final Thoughts

The V28 HCC model marks a deliberate shift from volume-based to value-driven diagnosis coding. For primary care providers, this is both a challenge and an opportunity.

By embracing accurate risk capture, they not only support better care coordination and clinical outcomes but also align with CMS's push toward equity and accountability in value-based reimbursement.

Early preparation, clinician training, and collaboration with Medicare Advantage Organizations are essential to navigating this transition successfully.

Get In Touch To Ensure You're Ready For V28!