Risk Adjustment 2025: Using Hierarchical Condition Categories to Protect Your MSSP Benchmark

CMS’s seismic shift to HCC V28 is here—and if your ACO isn’t prepared, your RAF scores could plummet, slashing your Medicare Shared Savings Program (MSSP) benchmarks regardless of patient outcomes.

The Urgency:

• 67% of 2025 RAF scores now hinge on V28’s stricter rules—more HCCs, reweighted conditions, and brutal specificity demands.

• Chronic conditions like CKD Stage 3 no longer count unless paired with complications. "Diabetes" alone won’t cut it—documentation must detail complications (e.g., "diabetes with neuropathy").

• Benchmarks = Revenue. Miss the mark, and shared savings vanish—or worse, your ACO triggers shared losses.

Your Survival Kit:

1. Audit Top Codes – Does your #1 diagnosis still map to an HCC?

2. Train Clinicians – V28 demands precision. "Good enough" notes = financial risk.

3. Leverage Annual Wellness Visits – Embed HCC recapture into every AWV.

4. Adopt MEAT Criteria – Every diagnosis must show ongoing Monitor, Evaluate, Assess, Treat.

5. Track Quarterly – Don’t wait for December—run RAF reports now.

 By 2026, V28 is 100% in effect. Delay = years of disadvantage.

Protecting your benchmark isn’t optional—it’s survival.