Healthcare leaders, coding professionals, and compliance officers joined us on July 23 for a crucial deep dive into the upcoming changes in CMS’s Version 28 Risk Adjustment Model. With major shifts scheduled to take effect on January 1, 2026, our experts— Kim Felix, RHIA, CCS and Jeanie Heck, BBA, CCS, CPC, CRC—offered timely guidance on how to prepare for the future of Medicare Advantage (MA) coding and documentation.
Why Now? Understanding the Urgency
While implementation is still months away, CMS’s May 2025 announcement signaled an aggressive expansion of RADV (Risk Adjustment Data Validation) audits beginning in 2026. CMS will now audit all eligible MA contracts annually—expanding record reviews from 35 to up to 200 per plan.
With MA payments increasing by over $25 billion, the stakes couldn’t be higher. Coding accuracy will directly influence risk scores and reimbursement outcomes, making early action essential.
Version 28: What’s Changing?
Version 28 represents a seismic shift from its predecessor (Version 24), with updates rooted fully in ICD-10 and designed to better reflect clinical relevance and patient health status.
Key highlights include:
- HCC Category Expansion: From 86 to 115 categories
- Code Deletions: ~900 codes will no longer map to an HCC—especially those for mild/remission conditions, sequelae, and acute events
- Code Additions: 268 new codes, including for:
- Malignant ascites and pleural effusions
- Severe persistent asthma
- Retinal vein occlusion
- CKD Stage 3A and 3B
- Anorexia and bulimia
- Rebalanced Diabetes Mapping: All types of diabetes now share the same coefficient, reducing weight for previously high-risk complications
- New “Constraining” Model: Related conditions (e.g., diabetes w/ and w/o complications) now receive the same risk weight—potentially lowering risk scores across the board
What Does This Mean for Providers and Coders?
While the changes aim to improve accuracy and eliminate inflated RAF scores, they also pose significant operational challenges:
- RAF Score Reductions Are Expected: Many chronic conditions—especially in remission or controlled states—will no longer drive risk scores.
- Documentation Specificity is Critical: Vague or unspecified diagnoses will no longer cut it.
- Primary Care Physicians Play a Key Role: Many chronic conditions—particularly behavioral health—are managed by PCPs. CDI professionals must ensure accurate outpatient documentation.
Preparing for 2026: Action Steps
✅ Audit Your Data – Focus on additions and deletions relevant to your population
✅ Educate Providers – Emphasize specificity in documentation
✅ Query Often and Early – Especially for unspecified or incomplete diagnoses
✅ Invest in Outpatient CDI – Critical for ongoing MA accuracy
✅ Use Technology Wisely – Let AI highlight risk gaps, but rely on human judgment
✅ Track Financial Impact – Know what’s changing and why
Stay Informed and Stay Ahead
This webinar was just the beginning. We’re committed to keeping you up-to-date on every development leading up to Version 28 implementation. If you missed the live session, catch the full replay here:
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Need Help Navigating the Changes?
Whether you’re looking to train your teams, update workflows, or audit for risk impact, e4Health is here to help. Our expert HIM, CDI, and coding consultants are already guiding organizations through Version 28 transition planning.
📩 Contact our team today to start a conversation about how we can support you in adapting to these changes and protecting your risk-based revenue.
Let’s navigate the future of coding—together.