CMS HCC-V28 is here! Are you prepared to navigate the regulatory changes in Risk Adjustment?


In the ever-changing realm of healthcare, the notion of value-based care (VBC) has gained substantial traction. At the core of this transformation lies risk adjustment – an essential element that ensures fairness and accuracy in reimbursement within VBC contracts. Our recent podcast episode titled “Navigating the Regulatory Seas: V28 Vs V24 | Risk Adjustment Ep 2” explored this intricate world of risk adjustment, shedding light on its incorporation into VBC contracts and the recent regulatory shifts that impact its implementation.

Hosted by industry expert, Dr. Fauzia Khan, CMO Persivia Inc., this enlightening discussion commenced by elucidating the significance of risk adjustment in value-based care models. Risk adjustment serves as the linchpin for equitable payment and care delivery, benefiting both healthcare payers and providers. Dr. Shannon I. Decker, a seasoned VBC professional, highlighted how recent regulatory developments have influenced the risk adjustment landscape, particularly the transition from V24 to V28.

A noteworthy concern addressed in the episode is the meticulous documentation of diagnoses. CMS and OIG are now closely scrutinizing the extent to which diagnoses are recorded, treated, and their frequency within a given time frame. Dr. Decker emphasized that if a crucial diagnosis, such as diabetes, is documented only once a year, it raises a red flag. Patients with chronic conditions need consistent care, and comprehensive documentation plays a pivotal role in ensuring their well-being.

The conversation took an intriguing turn as it explored the role of technology in risk adjustment. While technology can be a blessing, the episode underscored the pitfalls of relying solely on automated systems that generate conditions in progress notes. Dr. Decker expressed concerns about such systems lacking the depth of clinical judgment and evaluation that only a well-trained physician can provide. The message was clear – technology should enhance, not replace, the thoughtful assessment of patients.

A prevailing theme throughout the episode was the importance of a holistic patient view. Recognizing the bio-psycho-social aspects of healthcare, Dr. Decker and the host emphasized the need to consider social determinants of health. Addressing patients’ unique challenges, such as transportation or food issues, contributes to a more comprehensive and effective care strategy.

Furthermore, the discussion shed light on the pivotal role of healthcare teams in providing value-based care. Dr. Decker advocated for physicians to work at the top of their license, leveraging their expertise where it matters most. By delegating certain responsibilities to well-trained care managers and other team members, physicians can focus on rendering accurate diagnoses, crafting care plans, and driving positive health outcomes.

The episode concluded by emphasizing the power of data in shaping value-based care success. Beyond mere statistics, data tells a story – a narrative about patient populations, their needs, and the efficacy of care strategies. Dr. Decker recounted a revealing anecdote about a healthcare system that discovered significant gaps in its coding practices through careful data analysis.

As the industry navigates the changing tides of regulations and technology, the key takeaway remains clear – a patient-centric approach, empowered by intelligent systems and the expertise of dedicated healthcare professionals, holds the key to unlocking the full potential of value-based care.

Listen to the full episode here.