It is not a standard CMS upgrade to switch from HCC Model V24 to V28. This intentional recalibration rethinks how income is adjusted and patient risk is rated. Health systems, payers, and providers are now under pressure to interpret notable shifts in RAF ratings in light of the new risk adjustment model. The coding techniques of the past are no longer viable.
The Significance of the Transition from HCC Model V24 to V28
This change is mandatory. CMS has changed its approach by:
- Lowering the number of HCC classifications by more than 20%
- Making changes to factors that punish certain chronic conditions
- Introducing a clinical categorization approach that is more intricate (centered on ICD-10-CM)
Practical Implications of This
In the past, organizations relied significantly on the RAF scores’ predictive power. V28 removes some of the exaggerated numbers from V24 by calculating those scores via a new lens. You are already at a disadvantage if your team is not actively getting ready for this.
The V28 Framework’s Winners and Losers
By restructuring RAF scoring, the new risk adjustment model produces clear winners and losers. Based on the changes:
The winners are:
- Teams that handle patients with many systems and high levels of complexity
- Suppliers with excellent coding integrity and documentation
- Systems for longitudinal tracking that use cutting-edge data-driven platforms
Struggles for:
- Organizations using antiquated coding techniques
- Providers that place less of a focus on fully capturing the complexity of their patients
- Chronic illnesses that were formerly more significant are now less common or nonexistent.
RAF Scores Are No Longer Fixed
It is evident from the recalibration under HCC Model V28 that passive management of RAF scores is no longer an option. You are falling behind if you continue to measure them on a yearly or semi-annual basis.
What you now require:
- Reevaluating RAF scores every month or every three months
- Constant observation of the quality of the code
- Interventions in real time to guarantee precise condition recording
Dismantling the Legacy of ICD-9
A notable benefit is the complete departure from ICD-9 references. V28 now fully conforms to the structures of ICD-10-CM. This implies:
- The weight of diagnosis specificity is greater.
- Outdated or ambiguous coding techniques will seriously undermine RAF.
The problem is that a lot of staff operations and EHR systems are still conceptually tied to ICD-9 categories. You will pay a price for this legacy mentality.
The Function of Concurrent Coding in V28 Compliance
Concurrent coding is one of the most neglected techniques for efficiently manipulating RAF scores. The majority of businesses continue to use a retroactive method, however under V28, this is a revenue liability.
The importance of concurrent coding
- More effectively depicts changing chronic conditions
- Allows for course adjustment throughout the interaction.
- Matches actual patient acuity with real-time recording
After the switch, RAF scores have already stabilized for companies with strong concurrent coding operations.
Combining Administrative and Clinical Teams
You cannot afford to separate your administrative coders from clinical documentation improvement (CDI). The line between clinical input and coding output is significantly more blurred with V28.
The following should be the emphasis of integrated teams:
- Educating medical professionals on particular documentation phrases associated with high-weight HCCs
- Providing signs of illness progression to coders
- Feedback loops in real time to remedy unclear or missing documentation
Investment in Strategic Technology Is Now Necessary
You are in serious trouble if your analytics platform is not capable of managing V28-level detail. Analyzing data from the previous year and doing simple reconciliation reports is insufficient.
What a platform with V28 support has to have:
- Predictive analytics incorporating the logic of the new HCC model
- Performance drill-down dashboards for providers
- Warnings about possible dropped or undercoded codes
Never Undervalue the Significance of Missed Codes
The financial impact of dropped or uncaptured codes under V28 is greater. Refined weights make RAF volatility more responsive.
Proactive Audit Trails Can Save Millions
Audit trails that are proactive can save millions.
Under V28, audits are more detailed and precise. CMS will examine:
- Code-to-document traceability
- Congruence between risk assessment and encounter diagnosis
- Identification of exaggerated coding using patterns
To ensure that all reported high-weight conditions are accurate and genuine, you require clear audit trails.
Modifying Your Revenue Projections: Take Action Right Away
The majority of revenue teams have not yet adapted to the additional risk factors that are a part of V28. You are already projecting unrealistic expectations if you are still utilizing the forecasting model from the previous year.
To restart:
- Execute financial modeling in parallel for versions 24 and 28.
- Evaluate the impact for each patient segment (e.g., endocrine-heavy vs. CHF-heavy).
- Adapt care coordination tactics in light of potential additional revenue.
What V28 Looks Like for Success
Learning more code is not the key to success under V28. It has to do with proper code. It indicates:
- Early detection of lost income from insufficient risk assessment
- Retraining medical professionals in specific documentation
- Creating interdisciplinary teams that respond quickly to RAF reporting gaps
Must-Have Actions for V28 Adaptation
| Area | Action Required |
| Coding Accuracy | Refresher on ICD-10 specificity |
| Clinician Documentation | V28-focused training modules |
| Revenue Forecasting | Dual-run models (V24 vs V28) |
| Audit Preparation | Documentation-to-code mapping verification |
| Technology | AI-powered platform adoption |
Takeaway
The transition from HCC Model V24 to V28 is about more than just compliance. It immediately impacts your risk revenue. The new risk adjustment model changes how much money you make. Every transaction and interaction will include the losses if you continue to react rather than plan.
Keep forward. Make an investment in your coding processes. Rethink training for documentation. Make sure you have technology that knows, not guesses.
This evolution is not elective. It is a mandate for money.
Making the switch to HCC Model V28 is not a simple checkbox task. Expert processes and flexible technologies are required. The purpose of Persivia CareSpace® is just this. It combines real-time analytics dashboards, concurrent coding capabilities, and sophisticated risk adjustment logic to enable you to monitor RAF score changes in real time.
Providers and payers can prevent lost revenue opportunities and proactively manage patient risk with CareSpace®’s documentation guidance, audit-readiness, and value-based performance analytics.
