CMS introduced the phasing in of a new risk adjustment model, version 28 (V28), at the end of March 2023. The model is being phased in through 2025 and will ultimately replace model V24.

Under V28, more than 2,000 diagnosis codes no longer map to a risk-adjusted HCC, which means model changes more negatively impact chronically ill populations.

Keep in mind
V24 remains in place until 2025. Risk score calculation for 2024 dates of service is 33% of V24 and 67% of V28. Therefore, continue to document and code all present conditions, regardless of whether the conditions map to risk-adjusted HCCs under V28, because:

  • CMS could implement more changes
  • It ensures accuracy
  • Payment is still partially based on V24
  • We code for all diagnoses, not only for those with revenue-generating codes

CMS requires active diagnoses to be documented and coded annually to show that they are being assessed and managed by the physician and physician’s care team. Always code to the highest level of specificity, complexity (comorbidities) and accuracy possible for all applicable diagnoses. Consider reviewing the new diagnosis codes under V28, and consider focusing on historically under-coded, yet prevalent, diagnoses.

Commonly under-captured chronic conditions include:

  • Diabetes
  • Pulmonary disease/COPD
  • Heart failure/cardiomyopathy
  • Specified heart arrhythmia
  • Chronic kidney disease
  • Drug and alcohol use disorder
  • Major depression and bipolar disorders
  • Morbid obesity
  • Cancer
  • Rheumatoid arthritis
  • Vascular disease
  • Ulcers

More information
Talk to your Peoples Health representative to learn more about risk adjustment, including how V28 is being phased in.

For more about commonly under-coded chronic conditions, view our training Educational Initiatives Module: Staying Ahead of Patients’ Clinical Needs, which includes downloadable resources on chronic conditions.