The Essential Guide to the Revised CMS HCC Model – Version 28

The 2024 update to the CMS-HCC model, Version 28 (V28), is shaking things up for Medicare Advantage (MA) organizations. This revision impacts how risk scores are calculated, directly affecting reimbursement rates. V28 introduces a significant number of changes, including a jump in HCC categories, revamped code sets, and a phased implementation. Understanding these changes is crucial for navigating the new Medicare risk adjustment landscape. This guide equips you with the essential information to ensure a smooth transition under V28, maximizing both reimbursement and patient care delivery within the MA system.

We’ll explore the fundamental changes, potential impacts, and practical strategies to prepare your organization for success under the new model. By embracing accurate coding practices and potentially partnering with risk adjustment vendors, you can navigate V28 with confidence.

What is the CMS-HCC Model and Why Does It Matter?

The CMS-HCC model is considered a most significant tool for MA (Medicare Advantage) organizations. To provide a score, a risk-adjustment approach looks at a patient’s identified chronic conditions. This score corresponds exactly to the amount Medicare pays Massachusetts organizations for treating patients. Essentially, it reflects the expected healthcare costs for each patient. The model is crucial because it ensures fair compensation for MA organizations. Higher risk scores, indicating patients with more complex needs, lead to higher reimbursements. This allows MA organizations to provide adequate care while remaining financially stable.

Phasing in CMS-HCC Model V28

Over the course of three years, the CMS-HCC model V28 will be implemented, with a blend of 33% from the V28 model and 67% from the V24 model for service dates in 2023. Two thousand twenty-four service days will have a 67% usage rate of V28, while 2025 service dates will see a 100% implementation of V28. During the 2024 and 2025 service years, V24 will be employed at a rate of 33% and completely phased out, respectively. CMS thinks that updating the model will consider more recent trends in diagnosis, cost, and utilization. Along with increasing payment accuracy, the revised approach would lessen the discrepancies in codes between Medicare fee-for-service providers and MA plans.

The most notable modifications in V28:

  • The rise in the number of HCC categories from 86 to 115.
  • The HCC code (ICD-10-CM code) count dropped from 9797 to 7770.
  • There have been 268 new codes added and about 2294 removed.
  • Modifying and renumbering HCC categories.
  • Modifications to the risk scores that correspond to each HCC group or HCC coefficient values.

Potential Impact of V28

The updated model will likely have a range of effects on different stakeholders in the healthcare system.

  • Possible Drop in Total Risk Ratings: Because of how some illnesses are weighted and classified, industry analysts believe that V28 may result in lower overall risk scores. This might affect the sources of income for MA groups.
  • Pay Attention to Correct Diagnosis Coding: Revisions to category definitions and the introduction of new codes have made correct diagnosis coding even more crucial to obtaining a complete picture of a patient’s condition and guaranteeing proper payment.
  • Enhanced Significance of Medicare Risk Adjustment Vendors: Owing to the intricacies of V28, managed account companies can depend more on Medicare risk adjustment vendors possessing proficiency in data analysis, coding, and risk score enhancement. These suppliers can help with:
    • Finding holes in the code and making sure the documentation is in compliance.
    • Examining claim data to maximize the accuracy of risk scores.
    • Appealing the erroneous risk ratings that CMS assigned.

Preparing for V28 Implementation

In order to adjust to the changes brought forth by V28, a proactive approach is necessary. Key actions that MA organizations can take are as follows:

  • Train Employees on V28: Make sure that coders and healthcare practitioners are knowledgeable about the new V28 category definitions, codes, and coding procedures.
  • Purchase Coding Compliance Instruments: Make use of tools and resources that enable precise diagnosis coding according to the most recent V28 specifications.
  • Join Forces with a Medicare Risk Adjustment Vendor: Take into account joining forces with a respectable company that specializes in V28 implementation and continuing assistance for risk adjustments.

Mitigating the Potential Decrease in Risk Scores

Proactive steps can help lessen the impact of V28, even though a decline in total risk scores is potential. Using the new V28 codes, it is imperative to concentrate on recording all pertinent diagnoses with the right degree of specificity. This highlights how crucial it is for healthcare professionals to accurately and completely document their therapeutic work. Furthermore, it can be beneficial to collaborate with Medicare risk adjustment vendors who possess proficiency in conducting V28 coding compliance audits in order to detect overlooked diagnoses and guarantee adherence to appropriate coding procedures.

Leveraging V28 for Improved Patient Care

V28 offers a chance to improve patient care in addition to financial concerns. The enhanced level of detail in condition categorization may result in a more sophisticated knowledge of patients’ demands. MA organizations can more successfully tailor care management strategies and resource allocation by identifying patients with distinct chronic conditions at varying degrees of severity. This data-driven strategy may lower total healthcare expenditures while also improving patient outcomes.

Staying Informed and Adapting

The CMS-HCC paradigm is just one example of how the healthcare environment is constantly changing. MA organizations must remain up to date on any upcoming upgrades and revisions to V28, actively participate in industry discussions, and regularly evaluate CMS advice. By continuing to be flexible and continually improving their risk adjustment methods, MA companies may ensure they are well-positioned to prosper under the changing Medicare risk adjustment system.


Medicare Advantage payment determination has undergone a substantial evolution with the release of the updated CMS-HCC model (V28). Organizations in Massachusetts can easily manage this shift if they are aware of the main changes, possible effects, and practical planning techniques. Adopting precise diagnosis coding procedures and working with Medicare risk adjustment suppliers might be crucial to guaranteeing proper payment under the V28 framework as well as the best possible patient care.

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