The move to V28 Risk Adjustment is already underway, and providers are running out of time as CMS’s complete transition date in 2026 approaches. This is a major structural shift in how healthcare organizations are assessed and compensated for patient risk; it is not a gentle update. The V28 model is a drastic change that requires providers to rethink how they record, process, and handle patient data, whereas the previous model offered a little more freedom.
CMS’s objective is clear: rather than relying on past medical history or latent illnesses, it wants to recompense medically complicated people with active, treated problems. The way to comply, though? That is on top of operational friction, complexity, and actual financial risk. This is your warning if you have not started preparing for V28 yet.
What’s Changing in V28?
The V28 Risk Adjustment model is not only a repackaging of the V24 model. It remaps how ICD-10 codes affect risk rating and revamps the HCC structure. This entails retraining, realignment, and a thorough examination of documentation processes for providers.
Key Shifts That Will Affect Your Bottom Line
- HCC Expansion and Reorganization
With V28, there are 115 HCCs instead of just 86. The goal is to better match actual clinical complexity with coding. But this also implies that there is less space for assumptions and greater space for mistake.
- Major Reduction in Mapped ICD-10 Codes
The HCC mapping now includes about 2,294 diagnostic codes. There will be no risk-adjusted compensation for codes that were previously valid. These will have a detrimental impact on RAF scores if they are still in use.
- Constrained Coefficients on Chronic Conditions
Certain chronic illnesses, such as diabetes and heart failure, have had their effect limited by CMS. Even with adequate documentation, these might not have as much of an impact on the final score.
- Evolving Coding Rules
Limitations on the number of codes that can be included in the same hierarchy will now be visible to you. For example, only the most severe HCC will be counted if a patient has many within a hierarchy.
What This Means Operationally
The change affects all teams that work on value-based care, code, and documentation. Businesses must look at every stage of the risk adjustment process, from data input to the final CMS submission.
Common Gaps in Current Risk Adjustment Models
- Delayed Code Capture: A lot of systems use retrospective evaluations, which might result in missing or out-of-date diagnoses.
- Lack of Standardization: Inaccurate code might result from inconsistent documentation procedures.
- Inadequate Physician Engagement: It is possible that providers are not completely aware of what V28 requires for compliant documents.
- Data Silos: Incomplete patient profiles resulting from fragmented EHR systems limit the opportunity for risk collection.
Organizations must quickly adjust in order to respond, which includes updating technological tools, updating training programs, and better aligning clinical workflow.
Coding Compliance Is Now a Financial Imperative
The harshness of V28 Risk Adjustment is among its most noticeable changes. Clinical validation and active treatment throughout the encounter year are prerequisites for ICD-10 codes. An untreated ailment might not be eligible. Should your code fail to fulfill the new requirements, there will be a real financial penalty.
Why Accuracy Matters Now More Than Ever
- Wrong code = zero score
A code that was added to your RAF in V28 but was invalid in V24 is no longer valid.
- Missed conditions = missed revenue
Reimbursement declines when chronic and active conditions are not fully visible.
- Overreliance on History = no pay
We will not count codes that are solely based on prior medical history without proof of current therapy.
This is the amount of change we are discussing:
| Version | HCCs | Valid ICD-10 Codes | Avg. Expected Reimbursement Impact |
| V24 | 86 | 9,797 | Baseline |
| V28 | 115 | 7,503 | -3.12% CMS savings |
This 3.12% decline amounts to a predicted reduction in CMS payments of $11 billion. If providers do not adapt, that represents a revenue cliff.
Actionable Ways to Prepare for V28
Nobody has the luxury of waiting till 2026. Now is the time for organizations to take decisive action.
Perform a Full Coding and Workflow Audit
Examine your existing RAF procedure from the point of patient intake to the CMS submission. Determine the locations of missing codes, incomplete documentation, and lingering old ICD-10 codes.
Retrain Coders and Clinicians
Every team member must understand what matters, what is lacking, and how to adapt because V28 regulations are more stringent. Refresh training with an emphasis on:
- Verification of active therapy
- Logic in hierarchy
- Coding chronic illnesses correctly in light of new limitations
Use Advanced Tech for Documentation and Coding
AI and NLP-powered tools can identify documentation gaps and reveal missing codes in real time. A Digital Health Platform can facilitate proactive coding and compliance by including these technologies.
Restructure Data Aggregation Workflows
Combine patient-reported, unstructured, and structured data from laboratories, SDoH tools, EHRs, and other sources. Only when you consider the entire clinical and non-clinical picture does real risk become apparent.
Engage Providers at the Point of Care
Integrate coding logic into processes so that doctors are aware of what is important during a visit. Intelligent clinical decision support systems are superior than education.
A Glimpse into the Near Future
The gradual rollout method has already led to numerous payers combining the V24 and V28 models. Confusion results, but it also provides a window for testing. Begin monitoring your risk score in both models and project your potential revenue under complete V28.
Create dashboards to:
- Track the performance and preparedness of the code.
- Model the financial effect.
- Monitor gaps particular to providers.
- Assess the adherence to documentation.
Avoid last-minute confusion and financial shortages later by developing a cohesive clinical and coding approach today.
Takeaway
For healthcare companies, the switch to V28 Risk Adjustment is crucial. Although the CMS objectives are well-defined, the road necessitates a complete revamp of clinical interaction, documentation procedures, and coding standards. It involves more than simply coding; it involves developing a precise, legal, and proactive risk adjustment plan.
How Persivia Can Help
Persivia is familiar with V28’s data, technology, and regulatory levels. To keep coding teams and providers in sync, their solutions, which include their state-of-the-art Digital Health Platforms, automate HCC collection, combine structured and unstructured data, and offer NLP-driven analytics. They provide compliance without slowing down your business processes, from point-of-care tools to retrospective evaluations.
All in all, Persivia facilitates risk adjustment in real time, proactively, and intelligently, just as it should.
