For many PACE organizations, CMS-HCC Version 28 has created confusion during audit review. Diagnoses that are documented in the medical record, and may even reflect real clinical history, are still being challenged, removed, or downcoded. 

 

In most cases, the issue is not missing documentation. Instead, the issue is that the criteria CMS uses to validate diagnoses has changed.

 

Under V28, CMS is applying a narrower interpretation of what qualifies as a reportable condition. Auditors are placing greater weight on whether a diagnosis is actively managed, clinically relevant to the encounter, and supported by objective evidence. Conditions that were historically acceptable when documented may now fail validation if they do not meet these tighter standards, even when they appear reasonable to the care team.

 

This shift is especially important for PACE programs. High visit frequency, longitudinal care, and templated documentation can unintentionally increase audit exposure when diagnoses persist without clear evidence of reassessment. At the same time, many commonly documented conditions have been removed from the model entirely, eliminating reimbursement that cannot be recovered through documentation improvements alone.

 

And that distinction matters, because V28 did not simply change the codes. It changed what CMS considers acceptable in the first place.

 

V28 changed the definition of “acceptable,” not just the codes

 

Prior CMS-HCC models rewarded breadth. V28 rewards precision.

 

Many diagnoses that were historically easy to capture and reliably reimbursed were intentionally removed. CMS has stated that these conditions did not materially influence patient management or cost and were often documented solely for payment purposes. Once removed, no amount of documentation quality can recover their value.

 

This is why organizations are experiencing revenue decline even when documentation practices appear unchanged. The diagnoses still exist in the chart, but they no longer exist in the model.

 

For PACE programs, the implication is not to document more aggressively, but to redirect clinical effort toward the remaining diagnoses that still matter, and ensure those diagnoses can withstand scrutiny.

 

Why “documented” diagnoses fail under audit

 

1. Over-documentation of non-active conditions

 

One of the most common failure points under V28 is the inappropriate carry-forward of conditions that are no longer active or managed.

 

Typical examples include:

• • Acute inpatient diagnoses documented in outpatient follow-ups without evidence of ongoing treatment
  • Conditions listed as both “resolved” and “active.”
  • Chronic diagnoses included in the assessment without monitoring, evaluation, or treatment activity

 

Under CMS rules, HCCs require evidence that the condition was addressed during the encounter. Historically accurate conditions that are no longer managed must be coded as history, not as active disease.

 

In PACE environments, where patients are seen frequently and notes are often templated, this risk is magnified.

 

Organizations mitigating this risk are increasingly using automated chart intelligence, such as the AI Coder from DoctusTech, to review 100% of progress notes before submission, flagging diagnoses that lack clinical support, show template persistence, or conflict with the plan of care. This shifts compliance from retrospective cleanup to pre-audit prevention. 

 

Get a free demo to learn more about our AI coder. 

 

2. MEAT without evidence

 

While MEAT remains foundational, auditors now expect stronger objective substantiation, particularly for higher-value diagnoses.

 

Common audit failures occur when:

 

• • Diagnoses requiring imaging or diagnostics lack corresponding evidence
  • Asymptomatic but high-impact conditions are documented narratively but unsupported clinically

 

For PACE programs, where patients are often homebound, these gaps are operational, not clinical. However, CMS does not differentiate based on workflow constraints.

 

Audit-ready organizations address this by integrating diagnosis support directly into the clinical workflow. Platforms like the DoctusTech PDAP consolidate external data, prior imaging, labs, and specialist notes at the point of care, enabling clinicians to document with evidence visibility rather than after-the-fact reconstruction.

 

3. Template risk in high-frequency visits

 

PACE patients are seen often. When clinical status changes slowly, documentation often changes even more slowly. Auditors view repeated diagnoses without reassessment as high risk.

 

They look for:

• • Alignment between the physical exam and the assessment
  • Evidence of reconsideration, not repetition
  • Updates to management plans

 

To address this, leading programs pair automated template-risk detection with continuous clinician education. Short, targeted reinforcement, delivered in the flow of work, helps clinicians understand when diagnoses must be reaffirmed, revised, or removed. This model of education at scale is increasingly delivered via mobile microlearning tools, including those offered by DoctusTech, rather than annual compliance refreshers.

 

Documentation vs. submission: The invisible failure point

 

Not all failed diagnoses originate in the note. Some fail downstream:

• • Incorrect ICD-10 selection
  • Mapping errors during EDS submission
  • Silent rejections by intermediaries

 

Organizations without visibility across documentation, coding, and submission often discover these failures only after audits, when recovery is no longer possible.

 

Audit-ready programs reconcile these steps proactively, ensuring what is documented is what is submitted, and ultimately what is defensible.

 

Why PACE is both more protected and more exposed

 

PACE populations are clinically complex. Serious, high-value conditions remain in V28, cushioning overall RAF decline relative to healthier populations.

 

At the same time:

• • High RAFs attract audit attention
  • Smaller compliance teams concentrate risk
  • Medical directors often assume audit responsibility without a dedicated infrastructure

 

Under V28, reliance on manual oversight alone is increasingly unsustainable.

 

The strategic takeaway for PACE leaders

 

Under V28, a diagnosis can be documented, clinically reasonable, and well-intentioned, and still fail audit review.

 

The difference between failure and defensibility is no longer a matter of effort. It is the alignment between clinical reality, evidentiary support, and CMS expectations.

 

PACE programs that embed continuous education, automated documentation review, and point-of-care diagnosis support into daily operations are not trying to outwork V28. They are adapting to it, building documentation systems that can defend every diagnosis that remains.

 

Because under V28, the objective is no longer to capture everything. It is to defend what matters.