The shift from CMS-HCC V24 to V28 introduces meaningful changes that require a new approach to risk adjustment. What once worked, targeting a handful of high-impact codes, now falls short. Many payers and providers are finding their tried-and-true strategies are no longer delivering the lift they expected. Here’s the reasons why:

The Old Playbook Is Obsolete

Under V24, successful retrospective risk adjustment often relied on capturing a small set of impactful codes. But V28 rewrites the rules:

• Flattened Coefficients Across Related Conditions: Conditions like diabetes and congestive heart failure no longer deliver tiered risk adjustment value based on severity. This reduces the impact of capturing high-severity diagnoses.

• Common but low-bar diagnoses such as protein-calorie malnutrition and angina have been removed.

• Expansion of the Diagnosis Universe: V28 introduces over 200 new HCC-mapped codes, many of them rare (e.g., lysosomal storage disorders, porphyria). Identifying these requires deep chart review, clinical nuance, and advanced data tooling.

These changes aren’t minor adjustments. They fundamentally alter how risk is captured and rewarded.

This Isn’t Just a Model Update - It’s a Reset

V28 doesn't represent an incremental shift, it’s a fundamental change in how risk is captured and calculated. Teams relying on legacy coding workflows or limited point solutions are increasingly misaligned with the new structure. Strategies that worked well in V24 may now be yielding little to no value, or worse, creating blind spots that impact revenue and compliance.

A Modern Approach for a Modern Model

At HealthMC, we built our generative AI platform with V28 in mind. Our models identify relevant diagnoses based on clinical context, not billing patterns. This allows us to surface more complex, nuanced conditions at scale without relying on outdated shortcuts.

We haven’t just optimized coding, we’ve reimagined it to reflect the realities of today’s regulatory and actuarial landscape.