The transition to CMS-HCC V28 represents a structural shift in risk adjustment economics. For PACE programs, this is not a routine coding update; it is a recalibration of how revenue is generated, sustained, and defended.

 

V28 removes a meaningful subset of diagnoses that were historically prevalent and operationally easier to capture under prior models. As a result, most organizations will experience a decline in risk-adjusted revenue that cannot be fully recovered through documentation improvement alone.

 

For PACE programs, however, the impact is more nuanced. While certain lower-impact conditions no longer contribute to RAF, many high-severity, high-cost diagnoses common in frail, dual-eligible populations remain intact. Organizations that respond with speed and discipline can mitigate losses more effectively than peers.

 

What follows are the fastest, highest-confidence actions PACE leaders can take to stabilize performance under V28.

 

6 wins to close the V28 revenue gap for PACE programs

1. Quantify structural revenue exposure before optimizing operations

 

Before pursuing workflow or documentation changes, leadership must establish a clear understanding of non-recoverable revenue loss. This requires analyzing which V22/V24 diagnoses are being retired and estimating their historical contribution to RAF and capitation.

 

This assessment enables organizations to:

• • Distinguish structural model changes from operational underperformance
  • Set realistic financial expectations with executive leadership and boards
  • Prioritize initiatives that can materially influence outcomes

 

Absent this clarity, teams risk investing in low-yield optimization efforts that cannot meaningfully close the gap.

 

Platforms like DoctusTech’s PDAP are designed to support this type of analysis by aggregating structured and unstructured data across EMRs and external sources, allowing leadership to quantify risk with greater confidence and less manual effort.

2. Preserve eligible revenue during the transition period

 

Until V28 is fully implemented, diagnoses that remain valid under current payment models should continue to be documented and submitted in full compliance with CMS guidance.

 

Prematurely abandoning eligible conditions accelerates revenue erosion without improving future readiness. Revenue preservation during transition periods is cumulative and time-sensitive.

 

3. Reallocate focus to clinically complex, high-impact conditions

 

Under prior models, organizations could achieve acceptable performance by efficiently capturing a broad set of lower-complexity conditions. V28 materially reduces the contribution of those diagnoses.

 

Sustainable performance now depends on a deliberate shift toward:

• • Conditions with higher clinical severity and cost impact
  • Diagnoses requiring structured screening, testing, or longitudinal assessment
  • Documentation that must meet stricter evidentiary and specificity standards

 

This is an operational challenge, not a theoretical one. Success requires intentional workflow design rather than passive identification.

 

4. Strengthen documentation defensibility as margins compress

 

As aggregate RAF declines, the financial consequences of audits, payment adjustments, and recoupments increase. Documentation weaknesses that were previously absorbed by larger margins now pose disproportionate risk.

 

High-performing organizations are responding by moving beyond sample-based audits to continuous, scalable review. This includes:

 

• • Verifying MEAT support across all submitted diagnoses
  • Identifying internal inconsistencies between assessment, plan, and exam
  • Detecting patterns of inappropriate acuity or status carryover before submission

 

Manual chart review cannot scale to this level. DoctusTech’s AI Coder scans 100% of progress notes against MEAT, DSP, TAMPER, and internal compliance standards before submission, flagging gaps while remediation is still possible. When documentation gaps are flagged before claims submission, compliance becomes preventive rather than punitive.
Get a free demo to learn more. 

 

5. Use prevalence benchmarking to identify missed clinical burden

 

Comparing internal diagnosis prevalence against peer or national benchmarks remains one of the most effective methods for identifying under-recognized clinical conditions.

 

For PACE populations, where disease burden is typically higher, material variance often reflects missed opportunity rather than overperformance. This approach does not inflate risk; it improves alignment between documented and actual clinical complexity.

 

6. Deliver targeted, diagnosis-specific clinician education

 

Generic coding refreshers will not close V28 revenue gaps. Education must be:

 

• • Focused on diagnoses that continue to materially affect RAF
  • Grounded in current clinical and documentation standards
  • Reinforced consistently without disrupting care delivery

 

Organizations that succeed under V28 treat education as infrastructure, not remediation. Short, diagnosis-specific learning delivered regularly ensures clinicians stay aligned with evolving rules while minimizing disruption to patient care.

 

That’s why DoctusTech created a Mobile Learning App that supports weekly, personalized education tied directly to observed documentation behavior. This model supports consistency across teams and reduces downstream correction cycles for coding and compliance staff.

 

When education is individualized and operationally integrated, it becomes a mechanism for revenue protection and audit readiness, not a compliance afterthought. 

 

Takeaway for PACE leadership

The V28 revenue gap is structural and unavoidable. Its downstream impact, however, is highly variable.

 

PACE organizations that quantify exposure early, refocus on clinically meaningful diagnoses, and operationalize defensible documentation will stabilize faster and with less disruption. Those that rely on legacy workflows or retrospective remediation will face prolonged financial pressure.

 

V28 rewards rigor, transparency, and scalability. Organizations that operationalize those principles (rather than treating them as aspirational goals) will remain financially resilient in the next phase of value-based care.