CMS Risk Adjustment Changes for 2025: Key Updates for Primary Care Providers
CMS 2025 risk adjustment (HCC V28) demands precise documentation—chronic conditions now drive compliance and reimbursement.
Yan Mei Jiang, CPC, CPMA, CRC
11/27/20252 min read
CMS’s HCC Model V28 is reshaping how chronic conditions are documented and reimbursed. For primary care, this means greater emphasis on precision and compliance in everyday documentation.
Top 10 Condition Categories Most Impacted (and Why):
Diabetes (with complications) – Expanded specificity for complications (neuropathy, retinopathy, CKD) requires precise coding.
Chronic Kidney Disease (CKD) – Staging must be documented clearly; progression codes are weighted differently.
Congestive Heart Failure (CHF) – More granular coding for acute vs. chronic and systolic vs. diastolic.
COPD – Differentiation between emphysema, chronic bronchitis, and overlap with asthma is emphasized.
Hypertension (with complications) – Hypertensive heart disease and CKD linkage codes are critical for accuracy.
Depression & Major Mental Health Disorders – Mental health conditions now carry stronger risk weights in V28.
Cancer (active treatment) – Active vs. history of cancer coding clarified; outpatient documentation rules tightened.
Obesity & Metabolic Syndrome – Obesity-related complications (sleep apnea, diabetes) now risk-adjusted more heavily.
Rheumatoid Arthritis & Autoimmune Disorders – Expanded ICD-10 mappings require detailed documentation of severity and organ involvement.
Stroke & Neurological Sequelae – Post-stroke sequelae codes (I69 series) emphasized for accurate risk capture.
What Providers Should Do Now:
Document severity, complications, and linkages.
Update EHR templates to reflect new ICD-10 mappings.
Train staff on coding integrity and audit readiness.
Focus on chronic conditions that drive risk scores in value-based care.
Documentation Do’s & Don’ts for Primary Care Providers
✅ Do’s
Document with precision: Always capture severity, stage, and complications (e.g., “CKD stage 3 due to diabetes”).
Link conditions: Connect comorbidities clearly (e.g., “Hypertension with CKD”).
Use updated ICD-10 codes: Ensure EHR templates reflect new mappings for 2025.
Capture chronic conditions annually: Even if stable, they must be documented each year.
Specify mental health diagnoses: Include type, severity, and impact (e.g., “Major depressive disorder, recurrent, moderate”).
Note treatment status for cancer: Differentiate between active treatment vs. history.
Audit readiness: Keep documentation consistent with coding integrity standards.
❌ Don’ts
Don’t use vague terms: Avoid “history of” unless truly inactive; use “current” when appropriate.
Don’t omit staging or severity: CKD, CHF, COPD, and diabetes require detail beyond the base diagnosis.
Don’t forget linkages: Leaving out causal relationships (e.g., diabetes → neuropathy) reduces risk capture.
Don’t rely on problem lists alone: Ensure conditions are addressed in the visit note.
Don’t under-document mental health: General “depression” is insufficient—specify type and severity.
Don’t code inactive cancer as active: Only document active treatment when ongoing.
Don’t assume EHR auto-coding is correct: Review and validate codes against documentation.
Bottom Line: Accurate, detailed documentation ensures compliance, fair reimbursement, and better patient outcomes under CMS’s 2025 risk adjustment model.