For nearly two decades, Better Health Group has been a leader in value-based care and operating top-rated primary care clinics. Our network of owned and independent clinics leverage our model to improve care for both Medicare Advantage (MA) and Traditional Medicare patients. Now, the Centers for Medicare & Medicaid Services (CMS) has ranked Better Health Group in the top 5% of Medicare Shared Savings Program (MSSP), Accountable Care Organizations (ACOs) for performance year 2023.
At a time when independent clinics face mounting challenges, our providers are exceeding CMS quality goals and maximizing shared savings revenue, in every state in which we operate—Florida, Alabama, Georgia, Texas, Oklahoma, and Tennessee.
What Is Risk Adjustment?
Risk adjustment is the methodology Medicare uses to predict how much a patient's care is likely to cost, based on their documented health conditions and demographics, and to adjust payment accordingly. Rather than paying every provider the same flat rate per patient, CMS uses risk adjustment so that practices and plans caring for sicker, more complex populations are paid more accurately for that added complexity.
The tool CMS uses to do this is called the CMS Hierarchical Condition Category (HCC) model.
How Does HCC Coding Work?
Each year, CMS maps diagnoses into HCCs, which are groupings of conditions that are related clinically and cost-wise. CMS uses the CMS-HCC model to calculate each patient's risk score by using all the documented conditions, demographics, age, sex, etc. A score of 1.0 indicates average cost, higher indicates higher needs, lower indicates lower needs.
That risk score directly affects how much a Medicare Advantage plan (and, by extension, the providers and ACOs at risk for that patient's cost of care) is paid to manage that patient's health for the coming year.
Why HCC Coding Accuracy Matters More Than Ever
In 2024, CMS began phasing in a new version of the risk adjustment model, known as V28, which became fully effective for payment in 2026. V28 reduced the number of diagnosis codes that map to an HCC from roughly 9,800 to about 7,770, while increasing the number of HCC categories from 86 to 115. In practice, that means some diagnoses that used to be in the CMS model previously no longer do, and coding patterns that worked under the old model may now under-represent a patient's true complexity.
For independent practices, this isn't just a billing detail. Under-coding a patient's chronic conditions can mean a practice is compensated as if their patient panel is healthier than it actually is, which directly affects value-based revenue and total cost of care.
What This Means for Independent Practices
Accurate HCC coding depends on documentation that's specific, current, and captured face-to-face at least once a year, since risk scores reset annually and don't carry forward a diagnosis that isn't re-documented. Practices without dedicated coding support often under-capture chronic disease complexity.
FAQ
What does HCC stand for? Hierarchical Condition Category, the classification system CMS uses to group diagnoses for risk adjustment.
Do risk scores carry over from year to year? No. Diagnoses must be documented again during a face-to-face encounter each calendar year to count toward that year's risk score.
What is V28? V28 is the current CMS-HCC risk adjustment model, fully phased in for payment year 2026, replacing the previous V24 model.
What Is Risk Adjustment?
Risk adjustment is the methodology Medicare uses to predict how much a patient's care is likely to cost, based on their documented health conditions and demographics, and to adjust payment accordingly. Rather than paying every provider the same flat rate per patient, CMS uses risk adjustment so that practices and plans caring for sicker, more complex populations are paid more accurately for that added complexity.
The tool CMS uses to do this is called the CMS Hierarchical Condition Category (HCC) model.
How Does HCC Coding Work?
Each year, CMS maps diagnoses into HCCs, which are groupings of conditions that are related clinically and cost-wise. CMS uses the CMS-HCC model to calculate each patient's risk score by using all the documented conditions, demographics, age, sex, etc. A score of 1.0 indicates average cost, higher indicates higher needs, lower indicates lower needs.
That risk score directly affects how much a Medicare Advantage plan (and, by extension, the providers and ACOs at risk for that patient's cost of care) is paid to manage that patient's health for the coming year.
Why HCC Coding Accuracy Matters More Than Ever
In 2024, CMS began phasing in a new version of the risk adjustment model, known as V28, which became fully effective for payment in 2026. V28 reduced the number of diagnosis codes that map to an HCC from roughly 9,800 to about 7,770, while increasing the number of HCC categories from 86 to 115. In practice, that means some diagnoses that used to be in the CMS model previously no longer do, and coding patterns that worked under the old model may now under-represent a patient's true complexity.
For independent practices, this isn't just a billing detail. Under-coding a patient's chronic conditions can mean a practice is compensated as if their patient panel is healthier than it actually is, which directly affects value-based revenue and total cost of care.
What This Means for Independent Practices
Accurate HCC coding depends on documentation that's specific, current, and captured face-to-face at least once a year, since risk scores reset annually and don't carry forward a diagnosis that isn't re-documented. Practices without dedicated coding support often under-capture chronic disease complexity.
FAQ
What does HCC stand for? Hierarchical Condition Category, the classification system CMS uses to group diagnoses for risk adjustment.
Do risk scores carry over from year to year? No. Diagnoses must be documented again during a face-to-face encounter each calendar year to count toward that year's risk score.
What is V28? V28 is the current CMS-HCC risk adjustment model, fully phased in for payment year 2026, replacing the previous V24 model.
What Is Risk Adjustment?
Risk adjustment is the methodology Medicare uses to predict how much a patient's care is likely to cost, based on their documented health conditions and demographics, and to adjust payment accordingly. Rather than paying every provider the same flat rate per patient, CMS uses risk adjustment so that practices and plans caring for sicker, more complex populations are paid more accurately for that added complexity.
The tool CMS uses to do this is called the CMS Hierarchical Condition Category (HCC) model.
How Does HCC Coding Work?
Each year, CMS maps diagnoses into HCCs, which are groupings of conditions that are related clinically and cost-wise. CMS uses the CMS-HCC model to calculate each patient's risk score by using all the documented conditions, demographics, age, sex, etc. A score of 1.0 indicates average cost, higher indicates higher needs, lower indicates lower needs.
That risk score directly affects how much a Medicare Advantage plan (and, by extension, the providers and ACOs at risk for that patient's cost of care) is paid to manage that patient's health for the coming year.
Why HCC Coding Accuracy Matters More Than Ever
In 2024, CMS began phasing in a new version of the risk adjustment model, known as V28, which became fully effective for payment in 2026. V28 reduced the number of diagnosis codes that map to an HCC from roughly 9,800 to about 7,770, while increasing the number of HCC categories from 86 to 115. In practice, that means some diagnoses that used to be in the CMS model previously no longer do, and coding patterns that worked under the old model may now under-represent a patient's true complexity.
For independent practices, this isn't just a billing detail. Under-coding a patient's chronic conditions can mean a practice is compensated as if their patient panel is healthier than it actually is, which directly affects value-based revenue and total cost of care.
What This Means for Independent Practices
Accurate HCC coding depends on documentation that's specific, current, and captured face-to-face at least once a year, since risk scores reset annually and don't carry forward a diagnosis that isn't re-documented. Practices without dedicated coding support often under-capture chronic disease complexity.
FAQ
What does HCC stand for? Hierarchical Condition Category, the classification system CMS uses to group diagnoses for risk adjustment.
Do risk scores carry over from year to year? No. Diagnoses must be documented again during a face-to-face encounter each calendar year to count toward that year's risk score.
What is V28? V28 is the current CMS-HCC risk adjustment model, fully phased in for payment year 2026, replacing the previous V24 model.