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In risk-based care, your payment depends on your documentation and coding. We code documented chronic conditions and diagnoses to the specificity the record supports, in line with the ICD-10-CM Official Guidelines.
When documentation and coding fall short, risk scores don't match your patients.
The shift toward value-based care has fundamentally changed the economics of healthcare. Under Medicare Advantage and other risk-based payment models, your capitated reimbursement is not fixed, it is calculated. It rises and falls based on how accurately your patient population's true health burden is reflected in the diagnosis data you submit.
That calculation runs through Hierarchical Condition Categories (HCCs). The Centers for Medicare & Medicaid Services uses HCC coding to establish risk adjustment factors for each patient, which in turn determine the per-member per-month payment your plan or provider organization receives. Patients with multiple chronic conditions, complex comorbidities, and high-acuity diagnoses carry higher RAF scores. Higher RAF scores generate higher capitation payments. Each year's risk score is built from diagnoses documented during the prior calendar year (source: CMS risk adjustment).
For payment year 2026, CMS finished the three-year phase-in of the 2024 CMS-HCC model (V28). Medicare Advantage risk scores (other than PACE) are now 100% V28, with no V24 blend. Some diagnoses that mapped to payment HCCs under V24 no longer do, so documentation of severity and specificity matters more.
Source: CMS, Announcement of Calendar Year 2026 Medicare Advantage Capitation Rates and Part C and Part D Payment Policies, April 7, 2025.
We help close that gap. Our AAPC/CPC Certified Coders and Billers review charts against the documentation and the ICD-10-CM Official Guidelines, so valid, documented diagnoses are coded and your RAF scores reflect the patients you serve.
Six services, from prospective chart review through documentation support review.
We review member records before scheduled visits, flag chronic conditions that need to be addressed and documented again this year, and point out conditions the record suggests but doesn't yet document. We give providers a short clinical summary to use during the visit. The provider decides what to assess and document.
We review completed encounters across your Medicare Advantage population, starting with members who have known chronic conditions. We code diagnoses supported by the documentation and prepare them for your risk adjustment data submission.
We benchmark your current member-level risk scores against expected values based on demographic profiles and known clinical conditions, identify coding gaps by provider, site of care and condition category, and estimate their effect on capitation.
We manage the full coding workflow for Medicare Advantage risk adjustment, from chart review and diagnosis capture through quality review and submission file preparation. We track CMS model updates, such as the full move to V28 in 2026, and adjust our coding work to match.
Risk adjustment is not exclusive to Medicare Advantage. Commercial risk-based contracts, ACO participation, and Medicaid managed care arrangements increasingly incorporate risk adjustment mechanisms that reward accurate diagnosis capture and penalize coding gaps. MedixCode supports HCC coding programs across a range of value-based care arrangements, matching our coding to the model in use: CMS-HCC, HHS-HCC (the model behind the ACA risk adjustment program for individual and small group plans) or a payer's own model.
We review your highest-RAF members and highest-risk HCC categories to check that each coded diagnosis is supported by the provider's documentation. We flag diagnoses the record doesn't clearly support and work with your clinical documentation staff where it's clinically appropriate.
Most risk adjustment programs have the same categories of coding gaps. Recognizing them is the first step to addressing them.
A diagnosis of COPD that was documented in 2025 but not in 2026 does not count toward the risk score built from 2026 dates of service. Every chronic condition must be recaptured each calendar year. That's why chronic conditions need to be assessed and documented every year.
Diabetes coded as E11.9 (type 2 diabetes without complications) leaves out what the record may document, such as diabetic chronic kidney disease (E11.22, with an additional N18 code for the CKD stage) or diabetic polyneuropathy (E11.42). Coding at an unspecified level when the record supports more is a documentation inaccuracy and can understate the patient's risk.
Patients with complex chronic conditions frequently have secondary diagnoses that are documented in the clinical record but not assigned as coded diagnoses. Each uncoded instance is lost RAF value.
A diagnosis captured by a specialist may not be reflected in the primary care record. A hospital discharge code may not be carried forward into the outpatient chart. Without a coordinated coding program that spans care settings, these gaps accumulate.
MedixCode operates from a compliance-first framework. Every diagnosis we capture must be documented in the medical record, coded in accordance with ICD-10-CM Official Guidelines, and submitted through the appropriate data pathways.
Four reasons Medicare Advantage plans, ACOs, and provider organizations should consider MedixCode for risk adjustment coding.
Our coders stay current on CMS model updates, ICD-10-CM guidelines and payer submission requirements.
MedixCode manages the full risk adjustment coding cycle, member prioritization, prospective and retrospective review, coding audits, submission file preparation and reporting. You engage one partner for the complete program, not a collection of point solutions.
We review charts in the EHR your providers already use. You keep ownership of your data, and we're HIPAA compliant with HIPAA-trained staff.
Reports split your results by payer, provider, location and CPT, so you can see which provider or location a coding gap comes from.
Common HCC and risk adjustment coding questions we hear from health plans and provider organizations.
Didn't find your question?
Contact usA Hierarchical Condition Category is a diagnosis group used by CMS to quantify the expected healthcare cost burden of a Medicare Advantage enrollee.
Every year. CMS builds each payment year's risk score from diagnoses documented in the prior calendar year, so a chronic condition counts only if it's assessed, documented and coded again.
Prospective coding occurs before or during the care encounter, identifying conditions that need to be addressed and documented in the current visit. Retrospective coding reviews completed encounters for diagnoses that were present in the clinical record but not captured.
Every diagnosis we code must be documented in the medical record and coded to the ICD-10-CM Official Guidelines. We don't infer diagnoses or code from problem lists the clinical note doesn't support.
Yes. We check that each coded diagnosis is supported by the provider's documentation for that year. CMS validates Medicare Advantage diagnoses against medical records through Risk Adjustment Data Validation (RADV), so documentation support matters.
Book a free consultation. Tell us about your population and current coding process, and we'll talk through where documentation and coding gaps are most likely and how we'd work on them.
Have a risk adjustment question? Email info@medixcode.com or use our contact page.