Risk adjustment plays a critical role in healthcare reimbursement and population health management, making it essential for organizations to stay ahead of regulatory changes. The latest updates to the CMS-HCC (Hierarchical Condition Categories) model for 2025 introduce key shifts that will impact workflows, financial planning, and patient care. In a recent webinar, IMO Health experts June Bronnert, MHI, RHIA, CCS, CCS-P, SVP of Global Clinical Services, and Steven Rube, MD, FAMIA, Chief Clinical Officer, broke down what these changes mean and how to navigate them effectively.
Key Takeaways
1. Understanding the CMS-HCC 2025 Updates
The CMS-HCC model has undergone significant recalibration from version 24 to version 28, resulting in:
- An increase in HCC categories from 86 to 115
- A greater focus on chronic conditions (e.g., severe persistent asthma is now an HCC)
- Changes to numeric identifiers and risk adjustment factors for certain conditions
- Removal of some conditions, such as angina pectoris, from HCC classification
Watch June Bronnert break down these changes:
2. The Role of Social Determinants of Health (SDOH)
As healthcare moves toward a more holistic, patient-centric model, SDOH is playing an increasing role in risk adjustment. CMS has introduced new measures related to social needs screening and intervention, including identifying and addressing food, housing, and transportation insecurities.
Organizations that integrate SDOH data into their workflows will be better positioned for long-term success. IMO Health can streamline the capture of SDOH clinical data at the point of care with comprehensive terminology and code mappings. IMO Health’s normalization engine can extract and standardize SDOH data trapped in EHRs, making it usable and accessible to help optimize reimbursement and build precise value sets – helping drive better patient outcomes.
3. Preparing for RADV Audits and Compliance Risks
The Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) program is CMS’ primary way to address overpayments to Medicare Advantage Organizations (MAOs). However, CMS and the Office of Inspector General (OIG) have indicated more on areas of high improper payment risk, such as:
- Documentation inconsistencies in high-risk diagnoses like acute stroke and heart attack
- Questionable use of health risk assessments for unsupported diagnoses
- Increased extrapolation of audit findings, meaning errors could have financial impacts
Organizations must conduct internal audits and stay ahead of compliance requirements. It’s not a question of if you’ll be audited—it’s when.
Bronnert explains the importance of audit preparation:
How technology can help
As risk adjustment models grow more complex, healthcare organizations need technology that supports accurate coding, documentation, and compliance. IMO Health’s solutions help providers:
- Keep up with evolving HCC classifications through dynamic terminology updates
- Identify risk gaps by leveraging AI-powered NLP to analyze unstructured clinical notes
- Streamline problem list management to ensure accurate and complete coding
HCC capture doesn’t have to be a manual burden. Integrated solutions can help providers efficiently manage risk adjustment while staying focused on patient care.
Dr. Rube demonstrates how IMO Health’s workflow solutions support HCC management:
Q&A highlights: Expert insights
At the end of the webinar, attendees asked IMO Health experts about HCC best practices, compliance concerns, and workflow integrations. Here are some key takeaways from the discussion:
- How often should organizations review HCC conditions?
Bronnert recommends regularly assessing HCC documentation. Although CMS only requires conditions to be addressed once a year, some organizations choose to document them twice a year to support a more consistent revenue cycle. - Does IMO Health’s technology help eliminate duplicate conditions in documentation?
Rube responded that yes, IMO Health can make recommendations on cleanup, but it is always the final word of the clinician who will have to accept or reject those change recommendations. IMO Health does have the ability to provide cleanup functionality around three different items: duplicate conditions, expired problems, and conditions that have evolved over time. - How does IMO Health integrate with EHR systems like Epic?
IMO Health has been an integral partner with Epic and many other EHR vendors for years. Our industry-leading clinical terminology is fully integrated, helping to make clinical workflows as seamless as possible – and helping providers document to the highest specificity. - What steps should organizations take now to prepare for HCC changes?
Education is key. Organizations should ensure that both administrative and clinical staff understand the importance of complete, specific diagnosis coding. Leveraging technology can also simplify the transition.
What’s next? Steps to take now
To prepare for the CMS-HCC 2025 updates, organizations should:
- Conduct internal audits to ensure accurate HCC documentation
- Educate providers on the importance of complete and specific diagnosis coding
- Monitor CMS and OIG updates to stay informed on regulatory changes
- Leverage technology to streamline risk adjustment workflows
For a deeper dive into the conversation and learnings, watch the full webinar recording here.
Interested in seeing how IMO Health can help your HCC management? Schedule a demo here.
