HCC V24 to V28 Transition Explained: Risk Adjustment, Coding, and Value-Based Care - TaSonya Hughes
In this episode of the Move to Value Podcast, we take a deep dive into one of the most impactful updates in healthcare risk adjustment: the transition from CMS-HCC Version 24 to Version 28. Our guest, TaSonya Hughes, CHESS Health Solutions’ Manager of Coding and Documentation Education, explains what the shift means for providers, coding teams, and care managers—and why now is the critical time to prepare.
CMS-HCC Version 28 introduces new disease classification categories, retires thousands of existing diagnosis codes, and emphasizes greater specificity in clinical documentation. TaSonya walks us through how these changes affect Medicare risk adjustment, the financial sustainability of value-based care, and ultimately, the ability to deliver accurate, coordinated care for patients with complex chronic conditions.
Transcript
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those gaps before we get into:Welcome to the Move to Value Podcast, powered by CHESS Health Solutions. In this episode, we dive into the upcoming transition to CMS HCC Version 28, what it means, why it matters, and how providers can prepare. Our guest, TaSonya Hughes, Condition Management and Documentation Manager at CHESS, shares expert insight on improving documentation, supporting coding accuracy, and navigating the evolving world of value-based care.
Thomas Royal:So TaSonya to start us off, can you give a high-level overview of what the CMS, HCC coding model is an why it matters in healthcare today?
TaSonya Hughes:Yes. So the CMS, HCC coding model which also stands for hierarchical condition categories is really about helping Medicare understand how complex a patient's healthcare needs are. So if groups it groups together those certain chronic conditions that typically cost more to manage over time. For instance, like diabetes
or congestive heart failure. This model helps make sure the providers who care for those sicker patients are reimbursed more fairly. For example, if your patient has both diabetes and chronic kidney disease, their care is going to cost more to take care of those patients with those diseases versus someone that doesn't have those conditions. So, the HCC model actually reflects that complexity. So, providers aren't financially penalized for caring for those sicker patients. It's a key part of how value-based care works, tie in payment to the patients risk not just how many visits or tests that provider does for those patients.
Thomas Royal:Well, what prompted the shift from this HCC version 24 to the version 28?
And why is this change significant for providers?
TaSonya Hughes:So the shift from version 24 to version 28 is more about improving accuracy and better capturing those, the true complexity for those sicker patients, like for the providers, this means the codes are getting more specific. So, our documentation must be as detailed to support those changes. Take, for instance, peripheral vascular disease or PVD, for example, in version 28 now it's categorized more precisely based on the factors like do they have ulcers, or do they have a gangrene? That shift actually allows for a clearer picture of the patient's actual condition and the level of care it's going to take for that patient. So overall, Version 28 helps ensure that the sicker, more complex patients are more appropriately represented both clinically and financially within that version 28 model.
Thomas Royal:So it gives a better picture, a more detailed picture of the patient.
TaSonya Hughes:It does. It does, yes.
Thomas Royal:All right. So that's very interesting. So how does version 28 improve on version 24 in terms of capturing patient complexity and chronic conditions?
TaSonya Hughes:So one of the big improvements for version 28 is how it captures patient complexity in a more clinically accurate way. So compared to version 24, version 28 is much more focused on specificity. This means it does a better job of reflecting on how serious or advanced a condition actually is. As I use PVD earlier, so PVD a lot of providers use peripheral vascular disease unspecified a lot of times. Now with the version 28 they have to specify in their documentation, does it have gangrene, or do they have an ulcer? Because that's where the severity comes in. So, they have to document that severity. Whereas peripheral vascular disease now does not risk adjust or is attached to that HCC model 28 anymore. So again, it goes back to specificity when it comes to the documentation and the coding.
Thomas Royal:That's interesting. So, what are some of the key changes in disease classifications or coding categories that have been introduced in version 28?
TaSonya Hughes:It's one of the biggest shifts. So, with version 24 there were like 86 HCC categories now under version 28, we have 115 disease category categories. That alone shows how much more detail and specific this model has become. There were also over like 2000 diagnosis codes that were removed from the HCC model, while only just two hundred were newly added. So, the significant change this especially this is especially when you consider some of the familiar codes that we used to use what we used to call the low hanging fruit such as peripheral vascular disease or atherosclerosis of the aorta like those no longer maps to the HCC category Version 28, which they used to in the version 24.
Thomas Royal:How will the phased implementation occurring between 2024 through 2026 impact how providers report and document conditions?
TaSonya Hughes:So the phase implementation which we also know know as the blended model, which is what we're in right now, it started in 2023. So, this will affect providers by allowing them time to make sure their documentation is aligned with the version 28 model. Because again, it is more specific, so the documentation has to support those more specific codes. So, providers now have time to look at those opportunities that they have with the documentation and to make sure that their documentation is in alignment for version 28 and those more specific codes. As of 2026, we will be 100% in the version 28 model and at that time it will be100% providers documentation has to align with that version 28 model. So right now, they actually have time to look at their opportunities that they have.
For that.
Thomas Royal:What steps should health care organizations be taking now to prepare for full implementation of version 28 in 2026?
TaSonya Hughes:Now Is the most opportune time for them to lean into education and preparation. Everyone, including their providers, to their coders, to the CDI teams, really need to understand the significant changes that's coming in right now with version 28 and to make sure that again that they're coding and Documentation is being aligned with that version 28, so right now they have the perfect window to review current documentation habits and identify any of those gaps. Right. And making sure that their diagnoses and documentation are aligned together and they're very specific. Making sure that the language in their charts are supporting that those new HCC categories, those are the kind of questions that they really need to be asking themselves right now before we get into 2026. They should be updating their training materials, offering targeted provider education, running internal audits is very important to make sure that they can improve on their documentation. With that, so it's really going to be like a team approach as well as reaching out to me, their CHESS CMD manager for coding and documentation education, because that's what we're here for, to help them transition over into this version 28 model.
Thomas Royal:So are there specific challenges or pain points that you anticipate providers may face during this transition?
TaSonya Hughes:Yes. So honestly, being an educator for as long as I have for about 10 years, providers do tend to struggle already with the documentation. So, the transition to version 28 with this higher level of specificity could definitely feel like an added burden, but it's easy to see how this may come across as that. But it's really not. It's really just making sure the documentation is specific and aligns with the codes that are being used from the version 28 model is really not about doing more, it's just adding to what you're already doing. Providers are already doing the work. It's just about them putting it on in their documentation. Everything that they're doing and seeing and diagnosing the patients with those complex patients.
Thomas Royal:What role does accurate coding play in supporting value-based care and financial sustainability for providers?
TaSonya Hughes:So accurate coding and documentation really are the foundation of value-based care.
So when our providers clearly document each chronic condition that the patient has, CMS uses that information in the background to calculate the patient's risk score. The patient's risk score shows how sick the patient really is with all of their chronic conditions. So, if those diagnosis are missing, if they're too vague, then the true complexity is not captured for how sick that patient is. So then if we're not capturing that true complexity, then that's going to trickle down to the quality of quality of care for our patients as well as the financial reimbursement that it takes to take care of those patients that financial reimbursement will also go into different resources for those patients. So, the coding and documentation is the main piece to tell CMS really
how sick our patients are and if we don't, then again, it's like our patients could be likened to a checkbook. So, if we get the money that it takes from CMS to take care of the sicker patients, but we're not documenting and coding correctly, then now we're in the negative for our sicker patients and we don't have those funds to take care of those patients when the time comes.
Thomas Royal:Well, how does HCC V28 or version 28 align with the broader shift towards value-based care and improved patient outcomes?
TaSonya Hughes:So the HCC version 28 really aligns with the broader shift towards value-based care by putting the focus where it belongs on the quality of on the quality of care for each of our individual patients right? By accurately capturing a patient's full clinical complexity this allows the healthcare system to better understand what resources are needed to support that care. So, as I stated before, if we're not capturing that, that total picture of a complexity of the patients’ conditions, they're not, then we're not getting the proper reimbursement back for those patients to truly care for them so then that goes into again it trickles down to the quality of care for the patient. Because we don’t, we wouldn't then have the resources.
Thomas Royal:So beyond compliance and reimbursement, what are the potential benefits of version 28 for care coordination on population health management?
TaSonya Hughes:So this really helps strengthen care coordination, population health management when the patient complexity is documented more accurately, it allows care teams, including providers, the care managers to care coordinators to see the full picture and therefore the level of insight supports better care planning and helps ensure patients don’t fall through the cracks. Especially those with multiple chronic conditions, cause again, those are our sicker patients. So, from a population health perspective, version 28 gives healthcare systems better data to identify trends, stratify risk, even target interventions for those high need patients. Instead of a 1 size fits all approach, we're able to focus on what the patients really need for each patient as individuals.
Thomas Royal:Well, tell me to Sonya. What resources or support are available to help providers and organizations adopt V28 effectively?
TaSonya Hughes:So there are actually several resources out there to help providers and organizations navigate through the transition effectively. We have educational tools like webinars, workshops, continuing education resources, especially those led by experienced HCC educators like myself. We also have chart reviews and internal audits that are definitely powerful tools. I know a lot of times providers look at those as being negative. But when it comes from a place of partnership, then chart reviews and internal audits are really used as feedback opportunities so that it can help providers see where those opportunities are for them to better their documentation and coding.
Thomas Royal:How do you see the role of risk adjustment evolving as healthcare continues to move toward more patient centered value driven models?
TaSonya Hughes:Honestly, I believe risk adjustment is going to keep evolving. I've been saying this for a long time. I've been in risk adjustment probably since the beginning of my coding career, so I feel like healthcare systems will have to stay flexible and proactive to definitely keep up with it. It won't be enough just to implement changes once and move on, because as we can see coding and documentation value based on these models, they will continue to evolve. So, I really think it's going to keep becoming more patient centered, not just in theory, but in practice. It's going to be very important to take care of the patient through quality of care, through documentation, through coding, painting the full picture of what's really going on with those patients. Because again, at the end of the day, it is about the quality of care of the patient and that's where value-based care is. And again, I don't see it going anywhere. I just see it's going to continue to grow and become more specific and evolve into something bigger for the patients.
Thomas Royal:Well, TaSonya, is there anything during our conversation today that I failed to ask that you think would be important for our listeners to know?
TaSonya Hughes:No, I don't think you've left out anything. Again, I appreciate you having me on here.
The only thing I want to leave with providers is documentation is key. It's very important. Specificity is not going anywhere. Version 28 is about specificity, and if you have any questions at all, feel free to reach out to me. I'm happy to answer any questions when it comes to value based care or the version 28 transition model.
Thomas Royal:TaSonya Hughes, thank you for joining us today on the move to Value Podcast.
TaSonya Hughes:Thank you so much for having me. I appreciate you.