Preparing Your Healthcare Workflow for CMS-HCC Model V28 Compliance

CMS-HCC Model V28 is completely functional as of 2025 thus, healthcare organizations must immediately adapt their workflow. Among the significant changes are the elimination of 2,236 ICD-10-CM codes, the introduction of new disease categories, and stricter documentation requirements. Organizations must upgrade their coding techniques, train staff, and incorporate digital health systems in order to remain compliant and prevent financial loss.

Healthcare organizations face a critical transition period as the CMS-HCC Model V28 becomes fully operational in 2025. This updated risk adjustment model affects Medicare Advantage plans, requiring immediate workflow adjustments to maintain compliance and financial stability. Organizations that fail to adapt risk significant revenue losses and compliance penalties. The transition from V24 to V28 represents the most substantial change in risk adjustment methodology in recent years, demanding strategic preparation across all healthcare workflows.

What Is CMS-HCC Model V28?

The Centers for Medicare & Medicaid Services’ most recent risk adjustment model, CMS-HCC Model V28, is used to determine payments to Medicare Advantage plans. On January 1, 2025, the model was updated from Version 24 to Version 28, bringing about a significant shift in the way healthcare reimbursements and expenses are estimated.

The V28 model focuses on improved accuracy in risk prediction. The V28 model includes revised illness categories, updated disease relationships, and more exact coding standards designed to better represent actual healthcare costs and patient complexity.

Key Changes from V24 to V28

Why Does V28 Risk Adjustment Matter for Healthcare Organizations?

The financial performance and compliance status of your company are directly impacted by V28 Risk Adjustment. These changes will significantly impact risk adjustment factor (RAF) scores and how health plans and medical practices manage patient risk and allocate resources.

The financial implications are substantial:

• Revenue adjustments based on updated RAF calculations
• Compliance requirements with stricter documentation standards
• Potential penalties for inadequate coding practices
• Need for immediate workflow modifications

Healthcare companies need to realize that V28 represents a comprehensive overhaul of the way patient risk is evaluated and rewarded, not just a coding change.

What Are the Main Compliance Requirements for CMS HCC V28?

CMS HCC V28 requires adherence to specific documentation and code standards that change significantly from previous iterations. Organizations must implement comprehensive changes across multiple workflow areas.

Documentation Requirements

V28 documentation requires more clinical clarity and detail. Each diagnosis needs to be backed up by thorough clinical data that shows:

• Specific condition severity with exact staging or classification for accurate coding and care planning.
• Treatment plans and interventions that outline the therapies provided, medication details, and any procedures performed.
• Patient response to treatments, including observed improvements, setbacks, or complications during the care period.
• Ongoing monitoring requirements to indicate follow-up visits, future tests, or continuous care measures needed.

Coding Standards

The new model requires coders to:

• V28-Mapped ICD-10-CM Codes: Ensure all diagnoses align with the official V28 coding list for reporting accuracy.
• Provide Enhanced Specificity: Include detailed descriptors for each diagnosis to meet higher compliance standards.
• Document Comorbidities: Capture secondary conditions thoroughly, as they affect risk scores and care planning.
• Maintain Consistent Coding Practices: Apply uniform standards across all encounters to avoid discrepancies during audits.

Training Requirements

Staff training becomes critical for V28 compliance.

• Clinical Staff Education: Train providers on enhanced documentation requirements and the importance of detail in care notes.
• Coder Certification: Ensure coding staff complete V28-specific training programs for accurate reporting.
• Administrative Workflow Alignment: Prepare administrative teams to adapt to new workflows, timelines, and reporting processes.
• Quality Assurance Updates: Equip auditors with updated procedures for V28 compliance checks and risk adjustment validation.

How Should Healthcare Organizations Prepare Their Workflows?

The healthcare workflow must be prepared for V28 by carefully modifying a number of departments and processes. Technology, training, and procedural improvements must all be addressed at the same time by organizations.

Technology Infrastructure Updates

Modern healthcare organizations need a robust Risk Adjustment Solution to handle V28 requirements effectively. These platforms must support:

• Real-time coding validation
• Documentation tracking systems
• Quality assurance monitoring
• Compliance reporting capabilities

Staff Training and Development

A comprehensive strategy is needed to succeed under HCC Version 28: thorough understanding of the new model, careful clinical documentation, empowered and trained coders, efficient clinician-coder contact, and the strategic use of technology.

Training programs should include:

• V28 model fundamentals for all clinical staff
• Updated coding practices for medical coders
• Documentation best practices for providers
• Quality assurance protocols for supervisors

Process Optimization

Workflow optimization involves:

• Streamlined Documentation: Simplifies processes by reducing redundant entries and aligning templates with reporting requirements.
• Real-Time Coding Support: Integrates coding prompts during patient encounters to ensure accuracy and completeness.
• Quality Checkpoints: Embeds validation steps throughout the workflow to catch errors before claims submission.
• Continuous Feedback Loops: Provides teams with actionable insights to improve documentation quality over time.

What Documentation Changes Are Required?

V28 documentation requirements exceed previous standards significantly. Healthcare organizations must implement comprehensive documentation protocols that capture enhanced clinical detail.

Clinical Documentation Enhancement

Providers must document:

• Specific Diagnostic Criteria: Records symptoms and test results that justify each diagnosis for accurate coding.
• Severity Indicators and Measurements: Includes metrics such as lab values or staging to capture the full complexity of conditions.
• Treatment Responses: Tracks how patients react to prescribed interventions, including progress or complications.
• Comorbidity Details: Highlights how multiple conditions interact and influence the care plan.

Coding Documentation Support

Medical coders need access to:

• Detailed Clinical Notes: Supplies coders with precise language and descriptors to select the most accurate codes.
• Diagnostic Test Results: Provides interpretations that validate coding decisions for complex conditions.
• Treatment Histories: Documents therapies, medications, and responses for a complete clinical picture.
• Comprehensive Assessments: Captures risk factors and functional status to ensure risk adjustment accuracy.

Quality Assurance Documentation

Quality teams must maintain:

• Audit Trails: Maintains records of all coding choices for transparency and compliance reviews.
• Compliance Reports: Tracks adherence to regulatory requirements and internal standards.
• Training Records: Verifies completion of staff education programs to ensure readiness.
• Corrective Actions: Documents improvements made after audits to prevent recurring errors.

How Can Technology Support V28 Compliance?

By automating procedures, lowering errors, and guaranteeing uniform documentation standards throughout healthcare institutions, digital health platforms are essential to V28 compliance.

Automated Coding Support

Advanced coding platforms simplify risk adjustment by embedding intelligence into workflows. These tools go beyond static lookups and actively assist coders and clinicians with:

• Real-Time Coding Suggestions
  Offers immediate, context-aware code recommendations based on clinical documentation to avoid delays.
• V28-Specific Validation Rules
  Alerts users to any gaps or errors that might affect compliance with the latest risk adjustment standards.
• Duplicate Code Detection
  Prevents redundancy and ensures accuracy in claim submissions for cleaner data.
• Compliance Scoring and Reporting
  Provides built-in scoring systems and summary reports to maintain audit readiness and quality benchmarks.

Documentation Management

Effective documentation is critical for compliance and accurate risk capture. Modern technology platforms support providers with:

• Structured Documentation Templates: Guides clinicians to input essential details like condition severity and comorbidities in the right format.
• Clinical Decision Support Tools: Suggest best practices and prompts at the point of care to improve accuracy and reduce errors.
• Quality Metrics Tracking: Monitors performance indicators and aligns clinical documentation with regulatory expectations.
• Audit Preparation Assistance: Maintains a full record of documentation history and coding justifications for smooth audit processes.

Analytics and Reporting

Analytics transforms raw data into actionable intelligence, enabling proactive management of financial and clinical performance. Advanced platforms deliver:

• RAF Score Projections
  Forecasts risk scores based on current documentation trends, helping predict future revenue impacts.
• Compliance Metrics
  Tracks adherence to V28 requirements and identifies areas that need improvement.
• Risk Adjustment Trending
  Provides visibility into how coding and documentation changes affect overall risk capture over time.
• Financial Impact Assessments
  Highlights the monetary implications of coding gaps and compliance issues to inform leadership strategies.

What Are the Financial Implications of V28 Compliance?

Understanding V28’s financial impact helps organizations prepare budgets and resource allocation. The transition from V24 to V28 within the Medicare Advantage risk adjustment model is anticipated to yield a noteworthy 3.12% impact on MA risk scores by CY 2025.

Revenue Impact Assessment

Organizations should evaluate:

• Current RAF score distributions
• V28 model impact on existing patient populations
• Projected revenue changes under new calculations
• Investment requirements for compliance preparation

Cost-Benefit Analysis

Financial planning for V28 implementation requires a comprehensive look at both expenses and risks. Organizations must account for technology platform costs, staff training and development investments, and the resources needed for ongoing compliance monitoring. Ignoring these factors can lead to significant revenue losses due to non-compliance.

What Are Common Implementation Challenges?

Implementing V28 is not just a technical upgrade—it’s a strategic shift that impacts workflows, technology, and compliance systems. Healthcare organizations often encounter several hurdles that need proactive planning and strong leadership to overcome.

Staff Resistance and Training Gaps

Human factors remain one of the biggest barriers to successful adoption. Teams often struggle with:

• Resistance to Workflow Changes: Staff may push back against new documentation practices, fearing increased workload or reduced efficiency.
• Limited Training Time: Organizations often underestimate the time required for proper education, resulting in rushed or incomplete training.
• Varying Skill Levels: Different levels of coding and clinical knowledge create inconsistencies in documentation and compliance.
• Competing Priorities: Balancing day-to-day operations with training and system adoption can delay implementation progress.

Technology Integration Issues

Integrating new tools with existing systems can be complex and time-consuming. Common technical challenges include:

• Legacy System Compatibility: Older EHR or billing systems may not align easily with V28 requirements, requiring costly upgrades or custom integrations.
• Data Migration Requirements: Transferring historical patient data while maintaining accuracy can cause delays and compliance risks.
• User Adoption Difficulties: Even when systems are integrated, staff may hesitate to use them effectively without adequate support.
• Performance Optimization: Ensuring the platform runs smoothly across multiple departments often needs continuous fine-tuning.

Compliance Monitoring Difficulties

Maintaining compliance under V28 involves continuous oversight and detailed reporting. Challenges often include:

• Establishing Baselines
  Setting initial performance metrics for coding accuracy and documentation quality can be time-intensive.
• Creating Effective Audit Processes
  Building robust audit systems that catch errors early requires investment and dedicated resources.
• Maintaining Consistent Quality Standards
  Sustaining high-quality documentation over time demands ongoing monitoring and staff accountability.
• Addressing Compliance Gaps Quickly
  Failure to respond promptly to identified gaps can result in revenue loss and regulatory penalties.

How to Create an Effective V28 Transition Plan?

Successful V28 transition requires structured planning with clear timelines, responsibilities, and measurable outcomes.

Phase 1: Assessment and Planning 

The first phase focuses on understanding your current state and preparing for V28 adoption. This includes evaluating existing documentation and coding practices, performing a gap analysis against V28 requirements, and determining the resources needed. A clear implementation timeline is then developed to guide the transition.

Phase 2: Technology and Training Implementation

Implementation activities involve:

• Digital health platform selection and deployment
• Staff training program rollout
• Process documentation updates
• Quality assurance protocol establishment

Phase 3: Monitoring and Optimization 

The final phase is about maintaining compliance and improving efficiency over time. Key activities include:

• Performance Monitoring and Adjustments to track accuracy and close gaps quickly.
• Compliance Validation and Reporting to meet regulatory standards and internal benchmarks.
• Continuous Improvement Measures, informed by staff feedback and evolving best practices.

Essential Quality Assurance Measures 

Under V28, quality assurance is no longer optional; it’s a core requirement. With higher compliance demands and the financial risk of coding errors, healthcare organizations must implement structured QA processes to maintain accuracy and consistency.

Audit Protocols

Comprehensive auditing helps detect issues before they escalate. Effective programs should include:

• Monthly Coding Accuracy Reviews: Regular checks to verify that all submitted codes meet V28 requirements and are properly supported by documentation.
• Documentation Completeness Assessments: Reviews that ensure every diagnosis includes necessary details like severity, treatment plans, and comorbidities.
• Provider Feedback Sessions: Structured feedback loops that help clinicians understand errors and improve future documentation practices.
• Corrective Action Tracking: Documenting and resolving identified gaps promptly to prevent repeated compliance failures.

Performance Metrics

Tracking the right metrics is essential for ongoing compliance and financial health. Focus on:

• Coding Accuracy Rates: Measures how often coding matches documentation without errors or omissions.
• Documentation Compliance Scores: Evaluates adherence to required detail and specificity standards for V28.
• RAF Score Consistency: Monitors stability of risk adjustment factor scores to avoid revenue fluctuations.
• Revenue Impact Measurements: Tracks how coding quality directly affects reimbursement and financial outcomes.

Continuous Improvement

Quality improvement processes involve:

• Regular staff performance evaluations
• Process refinement based on audit findings
• Technology optimization and updates
• Best practice sharing across departments

Takeaway

Compliance with CMS-HCC Model V28 signifies a significant change in healthcare risk adjustment that all healthcare organizations must address right away. To preserve compliance and financial stability during the shift, extensive workflow modifications, improved documentation procedures, and strong technology support are needed.

Through careful planning, staff development, and technology implementation, businesses may proactively address V28 needs and position themselves for success in the evolving healthcare landscape. A successful transition depends on realizing that V28 compliance is a constant dedication to clinical documentation and coding standards excellence rather than a one-time event.

Begin Your V28 Compliance Journey with Persivia

Keep V28 compliance difficulties from overwhelming your organization. Persivia offers comprehensive digital health platforms specifically designed to support healthcare organizations through complex regulatory transitions. Our Persivia CareSpace® platform provides the tools and insights you need to maintain compliance while optimizing your risk adjustment processes.

Working together with Persivia will provide you access to modern technical solutions that ensure regulatory compliance, enhance code precision, and simplify documentation. Your clinical and administrative teams will receive real-time help from our platforms, which effortlessly connect with current operations.