The HCC Operator · July 2026 · Issue #3

V28 is 100% in. Now the RAF math is real.

Payment year 2026 is the first year of full CMS-HCC V28 weighting. The blend is gone. This issue covers what full V28 did to your captured RAF, the chronic-condition reset every January, and the documentation discipline that keeps the capture defensible. About 5 minutes.

By ASP-RCM Team Reading 5 min Issued 07.01.2026
Editor's note

For two payment years the V28 conversation lived in the future tense. That is over. Payment year 2026 runs on 100 percent V28 weighting, so the RAF you are capturing today is the RAF you are actually paid on. This issue is a compact operator's read: what the full model changed, the roundup you should be watching, and one move worth making before the quarter closes.

Lead Story · V28 full phase-in

The blend is gone. Full V28 is your payment model now.

CMS phased the 2024 CMS-HCC risk adjustment model (V28) in over three payment years to soften the transition off V24. Payment year 2024 paid on a 67 percent V24, 33 percent V28 blend. Payment year 2025 flipped to 33 percent V24, 67 percent V28. Payment year 2026 is 100 percent V28. There is no V24 component left in the payment calculation.

Full V28 is not a re-weighting alone. CMS restructured the model itself. The count of payment HCCs was reduced, several conditions were remapped or constrained so they no longer map to a payment HCC, and the ICD-10 to HCC crosswalk changed underneath codes that practices have billed for years. The net effect on a book that has not recalibrated is RAF compression: the same documented population produces a lower risk score than it did under the blend, and lower than it did under V24.

The categories that moved hardest are the ones many primary care panels lean on. Practices that rebuilt their PMPM and fee-schedule models against the 2025 blend are still under-modeling the downside, because the 2025 blend still carried a third of the old V24 weight. Payment year 2026 removes that cushion. The fix is not coding harder. It is documentation specificity at the chart level plus a V28 crosswalk audit of the most-used ICD-10 codes against their current category mapping.

CMS-HCC V28 PHASE-IN · PAYMENT YEAR SCHEDULE PY 2024 67% V24 · 33% V28 PY 2025 33% V24 · 67% V28 PY 2026 100% V28 FULL V24 (legacy) V28 (blend) V28 (full)
Source: CMS-HCC risk adjustment model, three-year V28 phase-in schedule.

Primary source: CMS Risk Adjustment.

The roundupFive things on the operator's radar.

Short items worth your attention this month. Each links to the primary CMS source so your compliance lead can verify before acting.

Recapture · Jan 1

Chronic HCCs reset every calendar year

Risk adjustment is a single-year model. Every chronic condition, even a lifelong one like CKD or diabetes with manifestations, drops off the risk score on January 1 and must be re-documented and re-submitted from a qualifying face-to-face encounter in the current year. A condition coded last year but not this year contributes nothing to this year's RAF.

CMS.gov · Risk Adjustment →
Suspecting

Suspect-condition identification

A suspect is a condition the record implies but has not yet documented and coded this year: a prior-year HCC, a lab value, a medication on the active list, a specialist note. Surfacing suspects as a pre-encounter prompt lets the provider evaluate and, where clinically supported, document them at the point of care rather than chasing them retrospectively.

CMS.gov · Risk Adjustment →
Documentation

MEAT is the evidence standard

A submitted HCC has to be supported in the note by evidence that the condition was Monitored, Evaluated, Assessed, or Treated during the encounter. A diagnosis carried forward on a problem list with no MEAT evidence in the current-year note is not defensible in a RADV audit. Document the clinical work, not just the label.

CMS.gov · RADV →
Capture

AWV is the structured capture visit

The Annual Wellness Visit is the one encounter type that forces a full chronic-condition review and a Health Risk Assessment on every Medicare patient, every year. It is the natural home for recapture and suspect resolution because the clinical workflow already requires reviewing the whole problem list inside a billable visit.

CMS.gov · AWV →
Workflow

Point-of-care prompts beat retrospective chart chase

The highest-yield place to close an HCC gap is inside the encounter, while the provider and patient are together and the clinical evidence can be generated in real time. Prompts delivered in the EHR template at the point of care, rather than a retrospective coder query weeks later, produce contemporaneous MEAT documentation and reduce the addendum and query volume that slows submission and weakens audit defense.

CMS.gov · Risk Adjustment →
RAFdrives PMPM
Stat of the month · the rule

Every point of RAF flows straight into per-member revenue.

Under CMS-HCC, a member's payment is the county or plan benchmark multiplied by that member's Risk Adjustment Factor. RAF is a direct multiplier on PMPM, so a compressed risk score is a compressed monthly payment on every attributed life, every month, for the full payment year. That is why full V28 is a revenue event and not just a coding update: the model change moves the multiplier on the entire book at once.

Operator's move

Capture compliantly. Document the condition, do not inflate it.

The move this month is to run every recaptured and suspect-driven HCC through a MEAT check before submission. The goal is complete, accurate capture of conditions the patient genuinely has and the provider genuinely addressed, supported by contemporaneous evidence in the current-year note. That is compliant capture, and it is exactly what a RADV auditor looks for.

Do not chase RAF by adding diagnoses the record does not support. Coding a condition that was not monitored, evaluated, assessed, or treated is not capture, it is exposure. Under full V28, the defensible play is documentation specificity paired with disciplined MEAT evidence, not coding intensity. Higher-specificity codes that reflect the real clinical picture hold their weight under audit. Inflated ones do not.

M
Monitored
E
Evaluated
A
Assessed
T
Treated
From the ASP-RCM bench

The V28 RAF Optimization Playbook.

We wrote down the full method: the V28 crosswalk audit, the recapture and suspect workflow, the MEAT documentation standard, and the AWV capture motion, in one operator's reference. If this issue was useful, the playbook is the long-form version with the checklists attached.

Read the V28 RAF Optimization Playbook →

Want to know what full V28 did to your RAF?

A free HCC and RAF audit. Send claims data for the last 12 months, your AWV completion report, and your provider roster. Inside 30 days you get a written read on V28 recalibration impact, recapture and suspect opportunity, and a 90-day fix plan. Yours to keep, no SDR follow-up.

Get my free HCC / RAF audit
Past issues

The HCC Operator archive.

Issue 3 · July 2026
The cap learns your RAF. The audits learn your book.
Issue 2 · June 2026
RAF attribution: where the lift actually comes from.
Issue 1 · May 2026
V28 condition map shifts and the recapture window.