HCC and Risk Adjustment: The Coder’s Edge in Value‑Based Contracts

In May 2025, CMS announced a major expansion of its Medicare Advantage audit program. The agency plans to increase annual audit volume from about 60 Medicare Advantage plans to approximately 550 and expand its medical coder staff from about 40 coders to approximately 2,000. Picture the federal government hiring nearly 2,000 coders for one purpose, which is checking whether the diagnoses behind Medicare Advantage payments hold up in the medical record. 

That decision says a lot about where risk adjustment is headed and about the coders who know how to do it well. Value-based contracts tie payment to how sick a patient population is expected to be. The coder is the person who translates a provider’s note into the codes that shape that expectation, and organizations now need that work to be precise enough to withstand the review process. 

How HCC Coding Connects to Payment 

Hierarchical Condition Categories, or HCCs, group diagnosis codes by the conditions most likely to drive the cost of care. Combined with demographic factors, a patient’s HCCs produce a risk score. The higher the score, the more complex and costly the patient’s care is expected to be, which influences reimbursement to health plans and provider groups. 

Medicare Advantage (MA) is where most of this money moves. More than half (55%) of eligible Medicare beneficiaries are enrolled in MA plans in 2026, and the Congressional Budget Office expects that share to reach 63% by 2034. Accountable Care Organizations (ACOs) use risk scores too, since an ACO’s financial benchmark is adjusted using each beneficiary’s HCC risk score. That means a coder with HCC experience can build a career on the payer side or the provider side. 

V28 Changed the Rules of the Game 

This year marks the first time Medicare Advantage runs entirely on CMS’s newest risk adjustment model, known as V28, after a three-year transition. The model expanded from 86 condition categories to 115, and it also dropped a large number of diagnosis codes that used to count toward a patient’s risk score. In some areas, related conditions now carry the same weight. Diabetes with complications and diabetes without complications, for example, now count equally toward payment. 

Habits built under the old model can lead coders astray. A code once relied on may no longer affect the score at all. Coders who have taken the time to learn V28 thoroughly bring something to an employer that a generalist may not. 

Audits Are Getting Bigger and Faster 

CMS’s audit push hit a legal setback in 2025, but the agency told Medicare Advantage plans in January 2026 that it would move ahead with accelerated audits and start new rounds every three months. For the organizations being audited, every diagnosis submitted for payment needs clear documentation showing the provider managed that condition during the year. 

This is where experienced coders earn their keep. Many teams use a simple framework called MEAT (monitor, evaluate, assess or address, treat) to test whether a note supports a code. Coders who apply that test consistently, and who can explain their reasoning to a provider or an auditor, help protect their employers from having to pay money back. 

Where Coders Fit In 

The risk adjustment roles opening up tend to call for a mix of skills like these: 

• Chart review, including catching conditions that were documented but never coded and conditions that were coded without enough support. 

• Provider education, since coders are often the ones who show physicians how a vague note could cause problems in an audit. 

• Audit preparation, such as pulling records and organizing documentation before deadlines arrive. 

• Comfort working alongside AI tools. CMS itself plans to use AI-enabled tools to support its coders, with all final determinations made by certified human coders. 

AAPC’s Certified Risk Adjustment Coder (CRC) credential focuses on this specialty, and current listings include risk adjustment positions that prefer CRC credentials. 

Built for the Long Game 

Risk adjustment rewards patience with a chart. The coder who reads the entire note and checks each diagnosis carefully before it goes out is doing exactly what value-based contracts depend on. With audits expanding and Medicare Advantage enrollment still climbing, that skill set should stay in demand for years. 

If you’re ready to move into risk adjustment or want a role that makes better use of the HCC experience you already have, Judge works with medical coders across payer and provider organizations and can help you find the right fit.