Healthcare organizations preparing for 2026 face a major shift in how Medicare Advantage plans calculate risk scores. The CMS-HCC Model V28 replaces the current V24 model, bringing hundreds of new diagnosis codes and stricter documentation standards. Health plans managing Medicare Advantage populations need to understand these changes now to avoid revenue disruptions and maintain accurate member risk profiles.

The transition affects every step of the risk adjustment process from provider documentation at the point of care to final CMS submissions. Organizations managing up to 30 distinct steps from clinical encounters to regulatory reporting must adapt their workflows, train staff, and update technology systems. The CMS-HCC Model V28 reshapes risk adjustment strategies across Medicare Advantage, requiring coordinated preparation across clinical, coding, and administrative teams.

What Is the CMS-HCC Model V28?

CMS-HCC Model V28 is the updated risk adjustment methodology CMS uses to calculate payments for Medicare Advantage plans starting in 2026. The model determines how much health plans receive based on patient health status and predicted healthcare costs. V28 replaces the V24 model used for payments through 2024.

The new version includes:

• Updated coefficient values for existing HCC categories

• New diagnosis code mappings reflecting ICD-10 updates

• Modified hierarchies between related conditions

• Refined calculations for demographic factors

Health plans use these risk scores to receive appropriate funding for members with chronic conditions and complex health needs.

Why is CMS Implementing V28?

CMS updates risk adjustment models to reflect current medical practices and healthcare costs. The V24 model no longer accurately represents today's diagnosis patterns and treatment approaches.

Clinical guidelines and treatment protocols have changed since V24 was created. V28 accounts for new standard-of-care approaches. The healthcare industry has shifted toward more specific ICD-10 codes, and V28 aligns with these detailed diagnostic classifications. Healthcare spending patterns have evolved, and V28 uses recent claims data to better predict actual costs for specific patient populations.

Major Changes in V28 Risk Adjustment

The V28 risk adjustment model introduces significant updates that affect how conditions are categorized, coded, and documented. These changes impact payment calculations and require organizations to modify their entire risk adjustment workflow. Health plans must understand each modification to prepare effectively for 2026 implementation.

Updated HCC Categories and Coefficients

The new model restructures how conditions map to risk categories. V28 modifies coefficient values that determine payment amounts for each HCC.

Here's what changed:

• Diabetes HCCs now distinguish between controlled and uncontrolled cases

• Mental health conditions have more granular categories

• Substance use disorders receive updated weightings

• Certain cancers show recalibrated risk scores

Some conditions that previously triggered higher payments now carry lower coefficients. For example, some conditions that previously triggered higher payments now carry lower coefficients. Other diagnoses that were undervalued in V24 receive increased weight in V28.

New Diagnosis Code Mappings

V28 introduces fresh ICD-10 code assignments across multiple condition categories. Codes that mapped to specific HCCs in V24 may now map differently or not at all. Cardiovascular conditions are split into more specific categories. Kidney disease stages are assigned distinct HCCs. Respiratory conditions show refined classifications, and neurological disorders have expanded categorizations.

Organizations must verify that documentation supports the specific codes required under V28 mappings.

Modified Hierarchies Between Conditions

CMS HCC V28 changes which conditions can be coded simultaneously. Some hierarchies that existed in V24 no longer apply, while new hierarchies prevent certain combinations.

The hierarchy rules work like this:

• More severe conditions within the same disease category suppress less severe ones

• Acute and chronic versions of related conditions follow new suppression patterns

• Certain comorbidities can now be captured together when clinically appropriate

Coders need updated training on these hierarchy changes to maximize appropriate risk capture.

Documentation Requirements

V28 demands more specific clinical documentation than V24. Providers must record precise details about disease severity, treatment status, and functional impact. Required documentation elements include current treatment plans for chronic conditions, disease severity indicators and staging information, functional status and daily living impact, and the presence and management of complications.

Vague or outdated documentation won't support V28 code requirements. Clinical teams need clear guidelines on documentation specificity.

How V28 Affects Different Stakeholder Groups

The transition to V28 creates distinct challenges and opportunities for each group involved in risk adjustment. Understanding these specific impacts helps organizations develop targeted preparation strategies. Every stakeholder, from health plans to providers to coders, faces unique requirements under the new model.

Impact on Health Plans

Medicare Advantage plans face revenue fluctuations during the V28 transition. Payment changes depend on member population characteristics and current documentation practices.

Plans must:

• Analyze member populations against V28 coefficient changes

• Project revenue impacts across different scenarios

• Update provider education and support programs

• Modify care management strategies for affected conditions

Plans with well-documented chronic disease populations may see neutral or positive payment impacts, while organizations with documentation gaps risk revenue decreases.

Impact on Healthcare Providers

Physicians and clinical staff handle an increased documentation burden under V28. The model requires more specific condition details and supporting clinical information. More detailed documentation can lengthen patient visits, adding to providers’ workload. Clinical staff need education on V28-specific documentation requirements to understand which details matter for risk adjustment coding. EHR workflows may need updates to capture V28-required information through modified templates and documentation prompts.

Impact on Medical Coders

Professional coders must master new code mappings, hierarchies, and documentation requirements. The transition requires significant retraining and reference material updates.

Coding teams need:

• Updated ICD-10 to HCC mapping tables for V28

• New hierarchy rules and suppression logic

• Documentation query templates for V28 requirements

• Quality assurance processes for V28 compliance

Coding accuracy directly impacts risk score accuracy and payment integrity under the new model.

Timeline for V28 Implementation

CMS implements V28 risk adjustment for payment year 2026, meaning diagnoses captured during the 2025 calendar year encounters determine 2026 risk scores and payments. Organizations must complete major preparation work before 2025 encounters begin to ensure a smooth transition and minimize revenue disruption.

Essential preparation activities include staff training programs that provide V28-specific education to clinical and coding staff. Technology updates for EHR systems, coding software, and analytics platforms require V28 configuration. Documentation improvement reviews help identify gaps against V28 standards. Financial modeling projects V28 payment impacts across member populations and develops mitigation strategies for potential revenue decreases.

Key Strategies for V28 Readiness

Successful V28 preparation requires coordinated action across multiple organizational functions. Organizations that implement comprehensive readiness strategies position themselves for smooth transition and revenue protection. The following approaches deliver measurable results when executed systematically.

Provider Education and Engagement

Physicians respond better to education that connects documentation to patient care rather than revenue. Frame V28 training around clinical accuracy and care coordination benefits.

Effective education approaches:

• Specialty-specific training sessions highlighting relevant conditions

• Real clinical examples showing documentation gaps and improvements

• Quick reference guides for common conditions by specialty

• Regular feedback on documentation quality with improvement suggestions

Provider engagement increases when organizations demonstrate value beyond compliance.

Technology and System Updates

Healthcare IT systems need V28 configuration across multiple platforms. EHRs, coding tools, analytics dashboards, and reporting systems all require updates. EHR template modifications capture V28-required details through condition-specific fields and prompts. Coding software must include current V28 mappings and hierarchy rules to prevent coding errors. Analytics dashboards should show V28 and V24 scores side by side during transition while tracking readiness metrics. Data integration through a digital health platform aggregates information from multiple sources to create complete patient pictures for accurate coding.

Documentation Improvement Initiatives

Systematic documentation improvement delivers better results than ad hoc approaches. Organizations need structured programs with clear metrics and accountability.

Documentation program elements:

• Regular chart audits identify specific improvement opportunities

• Provider feedback loops showing documentation impact on risk scores

• Clinical documentation specialists supporting high-complexity patients

• EHR optimization reduces documentation burden while improving quality

Quality documentation supports both accurate risk adjustment and better clinical care.

Testing and Validation Processes

Organizations should test V28 readiness before 2025 encounters count toward payment. Sample chart reviews reveal gaps in documentation and coding accuracy. Retrospective chart reviews apply V28 rules to recent historical charts and compare V24 and V28 scores to identify patterns and issues. Prospective pilot programs select provider groups or member populations for focused V28 documentation and coding. System validation tests technology updates with real data to verify that systems calculate V28 scores correctly and flag issues appropriately. 

Common V28 Implementation Challenges

Healthcare organizations face several obstacles when preparing for V28 implementation. Recognizing these challenges early allows teams to develop targeted solutions. The most significant barriers relate to system complexity, team alignment, and data integration across fragmented technology environments.

Multi-Vendor System Complexity

Healthcare organizations typically manage risk adjustment through multiple separate systems. Documentation happens in the EHR, coding in different software, analytics in third platforms, and reporting in yet another system.

This fragmentation creates problems:

• Data doesn't flow automatically between systems

• Updates in one platform may not reflect in others

• Staff manage manual workarounds and data transfers

• Errors multiply across handoff points

Organizations report managing up to 30 distinct steps from provider documentation to CMS submission. Each step introduces delay and error risk.

Clinical and Coding Alignment

Physicians and coders often work in silos with different priorities and knowledge bases. Providers focus on patient care while coders focus on accurate claim submission. Providers don't document the details coders need, requiring coders to query providers for information not recorded. This back-and-forth delays the coding process, and important risk factors go uncaptured. CMS HCC V28 amplifies these challenges with more specific documentation requirements.

Solutions for Successful V28 Transition

Organizations that implement integrated solutions and modern technologies navigate the V28 transition more effectively. These approaches address the root causes of common implementation challenges while improving overall risk adjustment program performance. Strategic investments in platforms and processes deliver both immediate and long-term value.

Integrated Risk Adjustment Platforms

Organizations moving away from fragmented multi-vendor environments see better outcomes. Integrated platforms handle documentation support, coding workflows, analytics, and reporting in one system.

Benefits of integration:

• Automated data flow eliminates manual transfers

• Updates propagate across all functions simultaneously

• Single source of truth for patient information

• Reduced administrative burden on staff

Platforms using advanced natural language processing can extract relevant clinical information from unstructured notes, making it available to coders and analysts. Persivia CareSpace® uses these AI capabilities to aggregate data from EHRs, clinical systems, social determinants of health sources, and patient-reported information into comprehensive longitudinal records.

AI and Natural Language Processing

AI-powered tools help identify HCC opportunities from clinical documentation. Natural language processing reads physician notes and flags conditions that may warrant HCC codes. AI applications scan notes for documented conditions matching HCC criteria, suggest documentation additions to support appropriate codes, flag hierarchy conflicts before claim submission, and identify documentation gaps for provider queries.

Technology handles the heavy lifting while humans make final clinical and coding decisions.

Transparent Provider-Centric Approaches

Providers respond better to risk adjustment programs that give them visibility and control. Transparent approaches show providers the clinical documentation supporting suggested HCCs and allow them to accept, reject, or modify suggestions. These systems explain how documentation improvements support accurate coding while providing prospective and retrospective views of opportunities.

When providers understand the reasoning behind suggestions, they engage more actively in documentation improvement.

Financial Implications of V28

Health plans will see varied payment impacts based on member demographics and condition prevalence. Some organizations may experience revenue increases while others see decreases.

Factors affecting financial impact:

• Current documentation completeness and accuracy

• Member population age and condition mix

• Provider documentation quality variation

• Coefficient changes for commonly coded conditions

Organizations investing in V28 preparation see better financial outcomes than those taking minimal action. Early investment in training, technology, and process improvement pays dividends. Revenue protection through better documentation and coding captures appropriate risk scores, preventing payment decreases. Efficiency gains from streamlined workflows reduce administrative costs per chart coded. Quality improvement, as enhanced documentation supports better clinical care coordination and outcomes.

Organizations should track both revenue impact and operational efficiency metrics to measure preparation success.

Best Practices from Industry Leaders

Successful V28 implementations involve coordinated efforts across clinical, coding, IT, and operational teams.

Effective team structures:

• Executive sponsorship ensures organizational commitment

• Clinical champions advocating among provider peers

• Coding leads, managing coder training, and quality

• IT teams handling system updates and integration

• Analytics staff tracking metrics and identifying issues

V28 preparation is not a one-time project. Organizations need ongoing monitoring, feedback, and refinement throughout 2024, 2025, and beyond. Monthly metric reviews track documentation and coding trends. Quarterly provider feedback sessions share improvement opportunities. Regular system testing validates calculation accuracy, and annual strategy reviews adjust approaches based on results.

Clear, consistent communication keeps everyone informed and engaged. Monthly newsletters highlight V28 preparation milestones. Training session schedules published well in advance keep teams prepared. Success stories showing positive outcomes from improvements motivate continued effort. Open forums for questions and concerns maintain transparency and trust.

Takeaway

The transition to CMS-HCC Model V28 requires immediate action from Medicare Advantage plans and provider organizations. Organizations that start preparation now, train staff, update systems, improve documentation, and streamline workflow will navigate the 2026 implementation successfully while maintaining revenue stability and coding accuracy.

Optimize V28 Risk Adjustment With Persivia

Preparing for V28 becomes challenging when systems operate in silos. Persivia CareSpace® simplifies risk adjustment end-to-end from documentation to CMS submission through an integrated population health platform. It unifies EHR, clinical, SDoH, and patient-reported data into longitudinal records, while AI-driven NLP uncovers HCC gaps, displays V24 and V28 views, and supports bidirectional data exchange back to EHRs. Clinicians gain clear, provider-friendly tools that streamline workflows, ensure accurate coding, and protect revenue throughout the V28 transition.

Frequently Asked Questions

Q: Will V28 increase or decrease Medicare Advantage payments?

No single answer applies to all organizations. Payment impacts vary based on member demographics, condition prevalence, and current documentation quality. Some plans may see increases while others experience decreases.

Q: Do providers need special training for V28 documentation?

Yes, providers need V28-specific training. The new model requires more detailed documentation about disease severity, treatment status, and functional impact than the previous V24 model.

Q: Can organizations code using both V24 and V28 during 2025?

Yes, organizations should use 2025 as a transition period. Running parallel V24 and V28 coding helps identify differences, test processes, and prepare for full V28 implementation.

Q: What happens if organizations don't prepare for V28?

No, unpreparedness creates significant risks. Organizations may experience revenue losses from undercoding, operational disruptions from workflow gaps, and compliance issues from documentation deficiencies.