CMS Just Deleted Two of the Easiest Ways You Were Capturing Diagnoses

When the 2027 Medicare Advantage Rate Announcement came out, almost all the attention went to the headline: rates went up about 2.48%. Plans exhaled.

They shouldn’t have. Underneath that number, CMS finalized two changes to how diagnoses can be captured that quietly reshaped the risk-adjustment math — and a lot of organizations haven’t connected the dots yet.

1. The two sources that just disappeared.

Two things held from the proposal into the final rule:

Diagnoses from unlinked chart reviews — those not tied to a qualifying encounter — are excluded from risk scores.
Diagnoses captured during audio-only telehealth visits are disallowed. The face-to-face requirement stands.

If a meaningful share of your risk capture has been flowing through either channel, your revenue just changed — without a single line of your clinical work changing.

2. A raise with one hand, a magnifying glass with the other.

This is the part to sit with. Yes, CMS raised rates. But at the same time it narrowed what counts as a valid diagnosis and expanded audits to every plan, every year. The agency has been explicit that it’s focused on curbing what it views as risk-adjustment “gaming.”

Read together, the message is unmistakable: the era of easy, loosely-sourced diagnosis capture is closing.

3. Why this is a revenue question, not just a compliance one.

Many organizations lean more heavily on chart reviews than their leadership realizes. If those reviews aren’t linked to qualifying encounters, the diagnoses they surface may no longer count — which means revenue you’ve been booking can quietly evaporate, without anyone flagging it until reconciliation.

The organizations that get surprised are the ones that never mapped where their risk capture actually comes from.

4. What to do now.

Three steps, in order:

Map your diagnosis sources. Know what share of captured conditions trace to chart reviews and telehealth, and how many are properly linked to qualifying encounters.
Quantify the exposure. Estimate the revenue tied to sources that no longer count.
Shift capture to defensible ground — documentation that originates in valid, face-to-face encounters and meets the audit standard.

Final Thoughts

The rate increase was the headline. The diagnosis-sourcing changes were the story. CMS gave the industry a small raise and, in the same breath, tightened the rules on what it will actually pay for.

If you don’t know how exposed your risk capture is to these changes, that’s not a reason to relax. It’s the reason to look.

Understanding where your diagnoses come from — and how much of that capture is still defensible — is exactly the kind of review I help organizations run.

1. The two sources that just disappeared.

2. A raise with one hand, a magnifying glass with the other.

3. Why this is a revenue question, not just a compliance one.

4. What to do now.

Final Thoughts

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