The Medicare Advantage landscape is quickly shifting.
Enrollment in Medicare Advantage keeps rising, reaching 32.8 million beneficiaries, or about 54% of the eligible population, accounting for $462 billion in healthcare spending. That growth brings increased pressure on everyone involved: clinicians, plans, developers, and the health systems trying to keep up with evolving requirements.
At the same time, the Centers for Medicare & Medicaid Services (CMS) is in the middle of one of the most significant Hierarchical Condition Category (HCC) risk adjustment model transitions to date. The movement from the 2020 CMS-HCC Model Version 24 (V24) to 2024 CMS-HCC Model Version 28 (V28) changes the number of HCC categories, the mapped codes, and the level of specificity required to accurately capture conditions. Many teams are discovering that navigating this shift is harder than expected, especially while managing daily workloads, ongoing updates, and documentation challenges.
Why V28 Requires a Different Level of Preparedness
HCC risk adjustment models use a patient’s documented conditions to calculate a Risk Adjustment Factor (RAF) score, which influences payment accuracy for Medicare Advantage beneficiaries. That makes quality documentation and coding essential. V28 increases the number of HCC categories from 86 to 115 and reduces the total number of mapped ICD-10 codes, pushing everyone toward more specific and clinically accurate documentation.
The transition is happening over three years. CMS introduced a blended scoring approach beginning in 2024, with weights shifting each year until V28 becomes fully effective in 2026. For teams working behind the scenes, keeping up with new terminology, annual ICD-10 updates, shifting clinical logic, and documentation practices requires more detailed, and likely more time-consuming, risk capture.
Developers and provider organizations often underestimate the ongoing work involved. From maintaining mappings to cross-linking content to tracking frequent coding updates, the maintenance load can become heavy quickly. As our team discussed during a recent internal meeting, even vendors that specialize in informatics struggle to manage the ongoing requirements for accuracy and consistency across standards such as Systematized Nomenclature of Medicine – Clinical Terms (SNOMED-CT), Logical Observation Identifiers Names and Codes (LOINC), RxNorm, and ICD-10.
The Practical Challenges of Getting HCC Coding Right
Anyone who has tried to build or maintain their own HCC logic knows how complicated it becomes. Even well-equipped development teams can find themselves spending enormous time validating code sets, updating logic, or troubleshooting mismatches when clinicians try to document complex conditions.
HCCs become even trickier when documentation is incomplete. A diagnosis documented early in the year that lacks specificity may not map correctly under V28. That gap can lower a patient’s RAF score, affect payment accuracy, and create a ripple effect across quality, compliance, and downstream analytics.
Add to that the rapid rise of Medicare Advantage enrollment, and it is clear why CMS is increasing oversight and audits. Organizations need reliable tools that help them capture the right information in the right way at the point of care.
How Quippe® Helps Organizations Stay Ahead of V28
This is where Medicomp’s Quippe Clinical Intelligence Engine makes a meaningful difference. Quippe was designed to simplify the work of capturing accurate, clinically rich documentation, including risk adjustment workflows. The platform brings together clinical data, terminology maintenance, documentation scoring, and coding support in an intuitive way for clinicians and a reliable way for developers.
Quippe offers several built-in capabilities designed to support HCC accuracy:
- HCC Indicators instantly identify diagnoses linked to HCC categories in the clinician’s workspace.
- HCC Recommendations highlight where additional specificity or updated documentation is needed to support accurate risk capture.
- Documentation Scoring checks documentation completeness so clinicians can fill gaps while they are still in the record.
These tools are built on a physician-curated data foundation that includes more than 400,000 clinical concepts, 10 million mappings to major standards, and 100 million diagnostic relevancy links. Quippe also maintains alignment with Fast Healthcare Interoperability Resources (FHIR) resources, annual ICD-10 updates, and evolving HCC logic, so developers do not need to maintain these models themselves.
Looking Toward 2026 with Confidence
With full adoption of V28 coming in 2026, organizations need solutions that support documentation accuracy, reduce manual coding effort, and keep pace with regulatory changes. Quippe helps teams bridge the gap between clinical documentation and risk scoring by turning fragmented data into structured intelligence that supports consistency, clarity, and compliance.
By integrating Quippe into existing electronic health records and health IT systems, organizations can reduce the guesswork and complexity that often surround HCC risk adjustment. This leads to cleaner data, better documentation, and a smoother transition to V28.
Future-Proofing HCC and RAF Scoring in Your System
If your team is preparing for the next phase of Medicare Advantage risk adjustment, now is the time to make sure your clinical documentation and coding workflows are ready. Quippe can help manage the transition with tools designed to make HCC accuracy easier for everyone involved. Schedule a demo today.