Problem List Accuracy: Why It Matters More Than Ever in 2026

As we move into 2026, primary care teams are facing increasing pressure to strengthen documentation integrity—especially under CMS’s evolving V28 risk adjustment model. One area rising quickly to the top of compliance priorities is problem list accuracy.

For years, problem lists have been treated as a static part of the EHR. But in today’s environment, an outdated or inaccurate problem list isn’t just a workflow nuisance. It’s a clinical risk, a compliance risk, and a barrier to delivering high‑quality care.

Why Problem List Accuracy Matters in 2026

CMS continues to refine risk adjustment methodologies, and with that comes heightened scrutiny on documentation that supports chronic conditions. A problem list that doesn’t reflect the patient’s current health status can lead to:

• Unsupported HCCs

• Increased audit exposure

• Care gaps

• Inefficient provider workflows

• Confusion during transitions of care

Accurate problem lists aren’t just about coding—they’re about ensuring the clinical story is complete, current, and defensible.

Key Areas Primary Care Should Prioritize

1. Distinguishing Active vs. Historical Conditions

If a condition is not being monitored, evaluated, assessed, or treated, it should not be coded. Keeping inactive or resolved issues on the list creates noise and compliance risk.

2. Annual Reconciliation of Chronic Conditions

Conditions like diabetes, CKD, COPD, CHF, and depression require intentional review at least once a year. This ensures they are still active, clinically relevant, and properly documented.

3. Removing Resolved or Irrelevant Problems

Old injuries, infections, or acute issues that have resolved should not remain indefinitely. A clean problem list improves clarity and reduces provider burden.

4. Linking Related Conditions Correctly

Specificity matters. Examples include:

• Diabetes with CKD

• Hypertension with heart disease

• COPD with asthma overlap

These linkages impact both clinical care and risk adjustment accuracy.

5. Avoiding Unspecified Codes When Detail Exists

V28 rewards precision. If the clinical documentation supports specificity, the coding should reflect it.

6. Strengthening Provider–Coder Collaboration

The most accurate problem lists come from shared workflows—not siloed ones. Regular communication between clinical and coding teams reduces errors and improves documentation quality.

The Bigger Picture: Better Care Through Better Documentation

When problem lists are accurate, everyone benefits:

• Providers make faster, more informed decisions

• Coders spend less time chasing clarifications

• Patients receive more coordinated, comprehensive care

• Organizations reduce audit risk and improve compliance

• Risk scores more accurately reflect patient complexity

Problem list accuracy is no longer a back‑office task. It’s a clinical quality practice—and one that will define successful primary care workflows in 2026 and beyond.