Risk adjustment year-end work means getting every patient with a chronic condition seen and documented before December 31. Diagnoses reset each January. A condition that isn't documented from a face-to-face encounter this year doesn't count toward next year's risk score. In Q4, pull your recapture list, rank it, reach patients, book visits and document.
Takeaways
V28 is fully phased in
For 2026 Medicare Advantage payments, risk scores come 100% from the 2024 CMS-HCC model (V28), which has 115 payment HCCs.
Every condition must be recaptured every year
Last year's diabetes diagnosis doesn't carry over. It has to be documented again.
The AWV is your best recapture slot
It's free to the patient and gives time to review every chronic condition.
Q4 is an outreach problem
The list exists. The hard part is reaching patients and getting them on the calendar before December 31.
What risk adjustment and RAF are
Risk adjustment changes what a health plan or ACO gets paid based on how sick its patients are. Sicker patients cost more to care for, so the payment or spending target goes up. Our risk adjustment glossary entry covers the basics.
The engine is the CMS-HCC model. HCC stands for Hierarchical Condition Category. It groups thousands of diagnosis codes into categories that predict cost. Each category carries a weight. See our HCC glossary entry.
A patient's RAF score (risk adjustment factor) adds up their demographic factors and HCC weights. A score of 1.0 is the average Medicare patient. Read more in our RAF score glossary entry.
What V28 changed
CMS phased in a new version of the model over three years.
- 2024: 33% of the risk score came from the new 2024 CMS-HCC model (V28) and 67% from the older V24 model.
- 2026: 100% V28, with no blend. That completes the phase-in.
V28 has 115 payment HCCs, up from 86 in V24. More categories doesn't mean more payment. V28 regrouped and reweighted conditions. Some diagnoses that used to map to a payment HCC no longer do.
What this means in practice: re-check your suspect logic. If your recapture list was built around V24 categories, some patients on it may not move the score under V28. Others now matter that didn't before.
Why annual recapture matters
Risk adjustment runs on a calendar year. Diagnoses from one year's encounters feed the next payment year's scores. Every January the slate is clean.
A patient with heart failure, diabetes with complications, and COPD has a high RAF this year. Suppose they're never seen next year, or are seen only for a sore throat with nothing else documented. Their next score falls to demographics only. The patient is just as sick. The payment to cover their care drops.
Recapture means documenting each chronic condition again, every year. The diagnosis must come from a face-to-face encounter with an acceptable provider. The note must show the condition was addressed, not just listed. Many coding teams use MEAT as a check: Monitored, Evaluated, Assessed or Treated.
Where the AWV and face-to-face visits fit
The Annual Wellness Visit (AWV) is the natural recapture slot. It's free to the patient when you accept assignment, and patients are eligible every 12 months. It includes a review of medical history and current providers. Clinicians can also bill a separate problem-oriented E/M visit the same day with modifier 25 when it's medically necessary. That's where chronic conditions get assessed and documented. Our AWV billing guide covers the codes.
Any face-to-face visit where the clinician addresses the condition counts. Chronic care visits, follow-ups and problem visits all work. The AWV just makes it easier because it's on the schedule anyway.
The Q4 checklist
- 1
Pull the suspect and recapture list
Start with every patient who had a payment HCC documented last year but not yet this year. Add suspects: patients whose meds, labs or specialist notes point to a condition that's never been coded. Use your payer or ACO gap reports plus your own claims export.
- 2
Check it against V28
Confirm each suspected condition maps to a V28 payment HCC. Remove items that don't so staff time goes to what matters.
- 3
Prioritize
Rank by number of open HCCs per patient, then by whether they've been seen at all this year. Patients with no 2026 visit go to the top. They also risk dropping from attribution.
- 4
Reach out
Call and text in order of priority. Lead with the free yearly wellness visit if the patient is eligible. Make repeat attempts for patients you don't reach.
- 5
Book the visit
Get the patient to a scheduler while they're on the line. Reserve slots for recapture visits in November and December, when calendars fill.
- 6
Prep and document
Give the clinician a pre-visit summary of open HCCs. After the visit, confirm each condition was assessed and the note supports it.
- 7
Track weekly
Count patients reached, booked, seen and recaptured. Re-queue no-shows and patients you couldn't reach.
Common Q4 mistakes
These show up every year:
- Starting in December. By then, schedules are full and patients are traveling. Start outreach in October.
- Chasing conditions that no longer pay. A V24-era suspect list wastes calls on diagnoses that don't map to a V28 payment HCC.
- Listing instead of assessing. A condition on the problem list, with nothing in the note, doesn't show it was addressed.
- One attempt and done. Patients who miss the first call often answer the second or third. Re-queue them.
- No one owns the list. If the list is shared by everyone, no one works it. Name one owner and review progress weekly.
What Rivvi does, and doesn't do
Rivvi fits steps 1, 3, 4, 5 and 7. It doesn't code, and it doesn't suggest diagnoses.
Find the list in your files. Upload your claims export, payer gap report or attribution file to the free patient analytics workspace. Ask which patients had HCCs documented last year and no visit this year. Uploads are enriched against CMS and NPI registry data. Rivvi works from what's in your files. Your coders confirm what's clinically valid.
Reach patients. On the Team plan, Rivvi calls and texts patients in priority order, in English, Spanish and 30 more languages. TCPA opt-out is honored on every path.
Transfer or task. When a patient wants to book, Rivvi warm-transfers them live to your scheduler. It can navigate your phone tree to reach the right department. If no one is free, it creates a follow-up task with the patient's details. Rivvi doesn't book into your EHR and doesn't write to the chart.
Log outcomes. Every attempt and result is recorded in Rivvi. If you've connected HubSpot, Salesforce or Zoho, outcomes are pushed there too. Your weekly tracking report builds from the same data.
For scale: Southeast Medical Group reached 104,000+ patients with Rivvi, with a 0.45% opt-out rate (August 2026). For more on gap lists, read our guide to building a care gap list from an attribution file.
Build your recapture list in minutes
Upload last year's claims and this year's visits. Ask who still needs to be seen.
The window is short. Every week in Q4 you wait, there are fewer open slots before December 31.
Get every chronic condition documented this year
Find your recapture list, reach patients, and track every outcome. Free for you and two colleagues, with a HIPAA BAA.