Health plans are under dual pressure: adapting to the structural changes of CMS V28 while preparing for the increased scrutiny of RADV Audits in 2025. Together, these forces are reshaping how documentation is created, reviewed, and defended. Success now depends on health plans building documentation practices that not only support accurate risk capture but also hold up under CMS’s evolving audit criteria.
Why CMS V28 Raises the Documentation Bar
CMS V28 redefines how conditions are grouped, weighted, and validated. Many broad or nonspecific codes that once carried risk now demand a higher level of clinical detail, such as staging, severity, or explicit causal links. This shift means documentation must evolve from being technically adequate to being highly specific and evidence-rich. Providers can no longer rely on generic entries—every note must clearly tie a diagnosis to its clinical context. This alignment between V28’s stricter coding requirements and the rigor of RADV reviews creates a new reality: incomplete or vague documentation is no longer just a missed revenue opportunity, it’s a compliance liability.
The Intersection with RADV Audits
While V28 tightens the requirements for valid codes, RADV audits ensure those codes are defensible. Auditors are increasingly focused on whether documentation meets MEAT standards—monitor, evaluate, assess, treat—across every diagnosis. This alignment between V28’s stricter coding requirements and the rigor of RADV reviews creates a new reality: incomplete or vague documentation is no longer just a missed revenue opportunity, it’s a compliance liability.
Building Audit-Proof Documentation Workflows
Health plans can prepare by embedding compliance into everyday workflows rather than treating it as a year-end process. This means:
- Training providers to document with the same specificity auditors expect.
- Equipping coders and CDI teams with tools that flag insufficient notes in real time.
- Running internal reviews modeled on CMS audit criteria to close gaps before they escalate.
By normalizing these practices, plans create a culture where audit readiness is a byproduct of daily operations.
Leveraging Technology as a Compliance Ally
Risk adjustment platforms powered by AI and NLP can detect incomplete documentation, highlight missed diagnoses, and ensure alignment with V28 requirements. When paired with skilled human oversight, these tools reduce error rates and prepare health plans for stricter audits. The goal is not just catching gaps—it’s preventing them.No software can replace the importance of provider engagement. Health plans must help clinicians understand how small documentation details affect both patient care and compliance. Showing the downstream impact of vague notes fosters accountability and improves adoption of best practices.
The Human Element: Provider Engagement
No software can replace the importance of provider engagement. Health plans must help clinicians understand how small documentation details affect both patient care and compliance. Showing the downstream impact of vague notes fosters accountability and improves adoption of best practices.
Conclusion
The convergence of CMS V28 and RADV Audits in 2025 is forcing a shift in how health plans think about documentation. It’s no longer enough to focus on coding accuracy alone—every entry must be specific, defensible, and audit-ready. By aligning provider education, coder training, internal audits, and technology investments, health plans can build documentation systems that meet today’s demands while protecting tomorrow’s revenue and compliance.
Risk adjustment platforms powered by AI and NLP can detect incomplete documentation, highlight missed diagnoses, and ensure alignment with V28 requirements. When paired with skilled human oversight, these tools reduce error rates and prepare health plans for stricter audits. The goal is not just catching gaps—it’s preventing them. CMS V28 redefines how conditions are grouped, weighted, and validated. Many broad or nonspecific codes that once carried risk now demand a higher level of clinical detail, such as staging, severity, or explicit causal links. This shift means documentation must evolve from being technically adequate to being highly specific and evidence-rich. Providers can no longer rely on generic entries—every note must clearly tie a diagnosis to its clinical context. While V28 tightens the requirements for valid codes, RADV audits ensure those codes are defensible. Auditors are increasingly focused on whether documentation meets MEAT standards—monitor, evaluate, assess, treat—across every diagnosis. This alignment between V28’s stricter coding requirements and the rigor of RADV reviews creates a new reality: incomplete or vague documentation is no longer just a missed revenue opportunity, it’s a compliance liability.
