How to successfully navigate the transition to CMS-HCC V28 for risk adjustment

Why CMS made the change from V24 to V28

The transition from CMS-HCC Model Version 24 (V24) to Version 28 (V28) reflects a strategic shift by CMS to enhance the accuracy and equity of risk adjustment. The updated model seeks to address coding inflation and ensure RAF scores better align with actual patient risk by eliminating redundant or less clinically significant codes. Additionally, V28 incorporates new HCCs that prioritize higher-risk conditions, emphasizing the need for precise documentation to accurately capture patient complexity. These changes aim to improve resource allocation for Medicare Advantage plans, reduce potential up-coding, and reflect a more standardized approach to assessing patient acuity across populations.

What V28 means for risk adjustment tools and processes

With the implementation of V28, health systems must confront:

1. Code elimination:
Thousands of codes that once boosted RAF scores have been removed, meaning some conditions will no longer factor into risk adjustment. As a result, conditions that previously buoyed RAF revenue in prior years – such as aortic atherosclerosis (ICD-10 I70.0) – are disappearing.‍

‍2. RAF score decline:
Even with accurate coding, the static scoring of patient populations is projected to result in a 5–30% drop in RAF scores industry-wide. This is not a reflection of your organization’s capabilities, but rather a systemic recalibration of the model.

3. Higher complexity:
The updated model introduces new HCCs that require more precise documentation and coding, demanding more robust workflows and attention to detail than ever before. For example, in V28, angina pectoris (ICD-10 I20.0) must be specified as ‘unstable’ in order to impact the RAF score.

While these changes will initially reduce the value of traditional suspecting tools, Notable will continue to develop robust V28 condition support. In addition, Notable is investing heavily in the “Algorithm Builder” sub-component of Flow Builder: the no-code solution that empowers our risk team – and your clinical/coding staff – to rapidly design and deploy custom suspecting algorithms without the need for dedicated engineering resources. Many organizations that fail to adapt will see significant declines, but Notable is positioned to minimize these impacts for your team and help you emerge even stronger than in previous years.

How Notable sets you up for success in the V28 era

At Notable, we’ve invested in the technology, expertise, and workflows to ensure your organization transitions seamlessly to V28. Here’s how we help:

1. Adapting existing workflows for V28:
We align your current workflows with the updated requirements of V28, ensuring that your teams focus on capturing the most valuable and high-risk HCCs. For example, we emphasize documentation for moderate or severe conditions, such as severe major depressive disorder (ICD-10 F32.1-F32.2), as unspecified or mild cases no longer qualify under the V28 model.

2. Adding high-prevalence, high-value V28 conditions:
Our solutions are designed to proactively expand coding accuracy for conditions that carry significant weight under the V28 model, such as severe persistent asthma (ICD-10 J45.50, 0.818 RAF) and other high-risk conditions. 

3. AI-driven precision:
Notable’s ability to leverage unstructured data, scanning dozens to hundreds of documents per patient chart, makes us well-positioned for condition suspecting under the higher complexity V28 model. Over 47% of our V28 suspects are generated from unstructured data hidden within these documents, with a 42% capture rate on V28 conditions such as congestive heart failure, COPD, chronic pancreatitis, and cirrhosis.

4. Enabling your teams with powerful AI:
With the new Flow Builder user interface, we are targeting Q1 2025 for end users to be able to design and deploy their own algorithms, leveraging Notable’s APIs and large-language models. This will allow you to create custom suspecting algorithms – leveraging Notable’s powerful underlying AI capabilities – based on your organization’s unique priorities and population health goals.

Moving forward together

We recognize that transitioning to V28 will present challenges and may initially lower RAF projections because of the updated model. However, these changes impact the entire industry, and while other organizations should plan for a decline in HCC documentation accuracy, Notable will help to minimize any impact. We’ve designed our tools and workflows to minimize disruptions and help you focus on high-value conditions to accurately reflect patient acuity and stabilize your RAF scores over time.

By partnering with Notable, you can remain confident in your ability to adapt to these changes and stay ahead of organizations that lack a clear strategy. Success in the V28 era depends on sophisticated tools and efficient workflows, and we are here to help you achieve both.

Let’s navigate this transition together and ensure continued success under V28. If you want to discuss this further, our experts are at the ready, including Dave Henriksen, Head of Value Based Care, and Dr. Aaron Neinstein, Chief Medical Officer.

• Dave Henriksen, Head of Value Based Care: dave.henriksen@notablehealth.com
• Dr. Aaron Neinstein, Chief Medical Officer: aaron.neinstein@notablehealth.com