Navigating Success Under HCC Version 28

CMS continually refines the Hierarchical Condition Category (HCC) model to ensure more precise and equitable reimbursement aligned with beneficiaries’ true health statuses. With the full implementation of HCC Version 28 for 2025 dates of service, Medicare Advantage plans, healthcare providers, and HCC risk adjustment coding professionals must navigate an environment that places heightened importance on specificity, thorough documentation, and ongoing quality improvement.

Whether you’re an experienced coder, a practice manager, or a healthcare executive, understanding how to thrive under the latest HCC model is essential. Below we’ll explore the key changes, best practices, and strategies for long-term success with HCC Version 28.

Understand the Key Updates in HCC Version 28

HCC models evolve to ensure that the payment structure remains aligned with patients’ true disease burden. Version 28 refines risk adjustment by:

• Reclassifying Certain Diagnoses: Some conditions may have shifted into different HCC categories or dropped altogether, impacting the risk score and associated reimbursement.

• Adding New HCC Categories: Emerging conditions and those previously grouped differently may now have their own dedicated categories for more precise scoring.

• Increased Focus on Comorbidities and Complexity: Patients with multiple, interacting chronic conditions may now be captured more accurately, encouraging comprehensive and holistic patient assessments.

Action Step: Start by reviewing CMS’s official HCC Version 28 mapping and changes. Ensure that your coding team and clinicians are aware of newly categorized conditions and any conditions that must be coded differently.

Elevate Documentation to a New Standard of Specificity

The foundation of accurate risk adjustment coding lies in clear, thorough, and specific documentation. Under HCC V28, coding to the highest level of specificity is more crucial than ever.

• Detail Disease Severity and Status: For chronic conditions (e.g., diabetes with complications, congestive heart failure, or chronic kidney disease), ensure the documentation reflects the current status and severity. Include staging, manifestations, and whether conditions are stable or exacerbated.

• Capture All Relevant Comorbidities: Providers should document all coexisting conditions that have a clinical bearing on the patient’s care—even those considered stable—as they often influence risk scoring.

• Link Conditions to Care Plans: Documentation should clearly show how each condition is monitored, evaluated, assessed, or treated (MEAT). This not only substantiates coding but also improves patient care continuity.

Action Step: Conduct provider education sessions focused on clinical documentation improvement (CDI). Offer pocket guides, templates, and checklists to remind clinicians of the required details.

Invest in Continuous Coding Education and Training

HCC coding is a specialized skill that demands ongoing learning. With each iteration of the HCC model, coders need robust training to maintain accuracy.

• Frequent Training Sessions: Host workshops on HCC Version 28 coding guidelines, emphasizing any new categories or conditions that have shifted.

• Utilize Real-World Examples: Present coders with case studies that illustrate how subtle differences in documentation and code selection can significantly impact risk scores.

• Certifications and Credentials: Encourage coders to maintain credentials and continuing education units (CEUs) through professional organizations specializing in risk adjustment coding.

Action Step: Partner with an AHIMA- or AAPC-approved training program for initial education and ongoing refresher courses, ensuring that your team stays at the forefront of HCC coding best practices.

Strengthen Collaboration Between Clinicians and Coders

The success of your risk adjustment strategy isn’t solely a coding department responsibility. Frontline providers, care coordinators, and coders must work in tandem to capture a patient’s comprehensive risk profile.

• Provider-Coder Communication: Establish a feedback loop between coders and clinicians. When coders encounter ambiguous documentation or missing details, they should have a direct line of communication to clarify and improve future documentation.

• Incorporate Risk Adjustment into Clinical Workflows: Embedding prompts into electronic health records (EHRs) using risk adjustment software can remind providers to detail conditions thoroughly at the point of care.

Action Step: Consider forming a multidisciplinary HCC committee that meets regularly to review coding patterns, documentation quality, and address any workflow challenges.

Leverage Technology and Analytics for Ongoing Improvement

Technology can significantly streamline the process of accurate HCC coding and documentation review. Modern risk adjustment platforms like ForeSee Medical have EHR-integrated tools with medical algorithms that can identify coding gaps, prompt for missing specificity, and track performance over time.

• Data Analytics and Dashboards: Harness analytics to monitor coding accuracy, identify trends, and pinpoint providers or departments that may need additional support.

• Natural Language Processing (NLP) and AI: Advanced solutions that use AI in healthcare like NLP can scan provider notes for missed or under-documented conditions, helping coders catch potential errors before claims submission.

• Predictive Tools: Use predictive analytics to anticipate high-risk patients and ensure they receive comprehensive assessments.

Action Step: Evaluate and implement risk adjustment software solutions like ForeSee Medical that integrate seamlessly with your existing EHR, providing real-time guidance on code selection and documentation standards.

Establish a Robust Compliance and Auditing Program

With increased scrutiny around risk adjustment, it’s imperative that organizations maintain a high level of compliance. Regular internal audits, external reviews, and adherence to CMS and OIG guidelines help mitigate the risk of penalties and ensure integrity.

• Internal Quality Checks: Perform periodic internal audits to confirm that computer assisted coding captures all relevant conditions. Cross-check these with clinical documentation and claims data.

• Third-Party Audits: Engage independent experts to validate coding accuracy and identify potential vulnerabilities.

• Prepare for CMS Audits: Keep your documentation organized and accessible. A proactive approach ensures that if and when CMS or other regulators review your data, you are ready.

Action Step: Develop a formal compliance plan outlining responsibilities, audit frequency, and corrective action processes. Make compliance training part of your coders’ and clinicians’ routine curriculum.

Stay Informed and Adaptable

The healthcare industry is dynamic, and HCC models will continue to evolve. Staying current with CMS announcements, industry conferences, webinars, and professional associations ensures that your organization isn’t caught off-guard by future changes.

• Continuous Learning: Subscribe to CMS announcements, risk adjustment newsletters, and professional journals.

• Network with Peers: Engage with other organizations navigating HCC Version 28 through user groups, LinkedIn communities, or local professional chapters. Share best practices and lessons learned.

Action Step: Appoint a “compliance champion” or “HCC lead” who is responsible for monitoring industry updates, disseminating information internally, and adjusting organizational policies as needed.

Looking Ahead

Thriving under HCC Version 28 requires a multifaceted approach: deep knowledge of the updated model, meticulous clinical documentation, trained and empowered coders, effective clinician-coder communication, and the strategic use of technology and compliance oversight. By investing in these key areas, your organization can position itself not only to meet the new standards confidently, but to excel—ensuring patients receive appropriate care and accurate risk adjustment in the evolving Medicare landscape.

Embrace the changes in HCC Version 28 as an opportunity to refine your processes and elevate the quality of both your clinical documentation and patient care. With a commitment to continuous improvement, your team will be well-equipped to achieve long-term success in the world of Medicare risk adjustment.

ForeSee Medical’s HCC coding software streamlines the V28 transition by leveraging AI-driven insights and automated prompts to improve documentation specificity and coding accuracy. It integrates seamlessly into clinical workflows, helping providers identify coding gaps and prioritize high-risk conditions in real-time. With robust analytics, it offers transparent reporting, tracks performance, and ensures compliance, ultimately empowering your organization to enhance revenue integrity, maintain quality care, and confidently navigate the evolving risk adjustment landscape.

Blog by: The ForeSee Medical Team