The transition from the hierarchical condition category (HCC) coding model version 24 (V24) to version 28 (V28) marks a significant shift in the evolution of healthcare risk. For providers, adopting updated coding systems ensures accurate risk adjustment, appropriate reimbursement, and improved outcomes. CMS-HCC Model Version 28, which will be fully implemented in 2026, introduces more specific disease classifications to better capture patient complexity.
The HCC coding system, used for risk adjustment in Medicare Advantage plans, plays a key role in predicting healthcare costs based on the severity of patients’ conditions. HCC V24, introduced in 2020, laid the foundation for capturing diagnoses and conditions that reflect chronic illnesses and comorbidities prevalent in Medicare populations. By using V24, healthcare professionals were able to accurately document these conditions, helping payers and healthcare organizations allocate resources to more effectively manage patient care.
However, as healthcare delivery and patient needs have evolved, so must the tools used to assess patient risk. CMS-HCC Model Version 28 represents a more refined approach to coding, expanding on the previous system by incorporating a broader range of conditions and more precise categories. This update reflects an enhanced understanding of the complex needs of Medicare beneficiaries, emphasizing chronic disease management, comorbid conditions, and newer insights into healthcare outcomes. With HCC V28, healthcare professionals can more accurately document the severity of patients’ conditions, allowing for a better representation of the true risks associated with caring for these individuals.
To allow providers and organizations adequate time to adjust to these new changes, the implementation is phased. Starting in 2024 and continuing into 2025, risk scores are calculated using a blend of V24 and V28. By 2026, risk scores will be calculated using only CMS-HCC V28.
The transition to CMS-HCC V28 reflects the broader shift towards value-based care. As value-based care models emphasize improving outcomes while controlling costs, it is increasingly important to have a coding system that accurately reflects the health of patients. CMS-HCC Model Version 28 allows providers to capture the full complexity of patients’ conditions, ensuring the financial risks associated with patient care are appropriately managed. For providers and healthcare organizations, understanding and adopting this new HCC coding model is crucial to reimbursement and ensuring compliance with evolving regulations.
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