Ease the transition from V24 to V28 by knowing ICD-10-CM codes that map to CMS-HCCs

By Brian Murphy

 

CMS document provides comprehensive list of HCCs in V28

 

The ongoing transition from CMS-HCC Version 24 (V24) to V28 has introduced several notable ICD-10-CM codes that now map to HCCs. These are available in an excel file on the CMS website.

 

I thought I’d share a few that stand out to me, from my non-clinical perspective. Previously, these diagnoses did not map to any HCC in V24.

 

• Bulimia Nervosa (F502). Interesting that unspecified or mild forms of bulimia fall into the same HCC (153) as severe or extreme. Bulimia nervosa in remission (F5025) also holds weight.
• Alcoholic Hepatitis (K7010-K7011): Both with and without ascites, alcoholic hepatitis has been added to the HCC list, acknowledging the toll it plays with increased healthcare utilization and mortality risk.
• Malignant Pleural Effusion (J910)
• Obstruction of the Bile Duct (K831).
• Severe Persistent Asthma and its subtypes (J4550-J4552). Of course this makes sense, but notable that unspecified asthma, even with acute exacerbation (J45901) holds no weight in V28. Which means providers must specify type.
• Toxic Liver Disease with Chronic Persistent Hepatitis (K713) and various subtypes (K714, K7150, K7151, K717): These conditions underscore the importance of capturing liver-related diseases in risk assessments.

 

It probably goes without saying (I’ll say it anyway) that knowing what these new conditions are is only part of the work. CDI and coding professionals must educate healthcare providers to document them with specificity, ensure assistive code capture software is updated, problem lists addressed, coding staff trained, etc.

 

There is much additional detail to be analyzed in this file. For example, V24 breaks out dementia into just two buckets; with complications (HCC 51) and without (HCC 52), while V28 further classifies by severe (125), moderate (126), and mild or unspecified (127)—but strangely all have the same RAF score (0.341).

 

Why does this matter?

 

The 2026 Medicare Advantage advance notice was released a couple weeks ago, putting everyone on notice that V28 will be fully implemented in the final rule.

 

2025 is the last year of the three-year phase in from V24, with 33% weight deriving from that model and 67% from V28. Starting Jan. 1 2026 the transition will be completed, and V28 100% in play.

 

Many ICD-10-CM codes that used to add RAF weight no longer will in V28. This includes many categories of codes, with diabetes particularly hard hit. Which makes capturing new codes like I’ve described above an imperative.

 

Of course all nonspecific/conflicting/incomplete/ambiguous/inconsistent documentation should be clarified, regardless of financial impact. But knowing what officially counts toward risk adjustment gives you a place to focus your efforts.

 

Credit to Danielle Bagnell for offering a direct link to the 2025 Model Software/ICD-10 Mappings. CMS’ website is NOT easy to navigate, for anyone who’s tried. I’ll include the link in the comments so that you can bookmark it.

 

Reference

CMS.gov: https://www.cms.gov/medicare/payment/medicare-advantage-rates-statistics/risk-adjustment/2025-model-software/icd-10-mappings