CMS May Ban Unlinked Chart Reviews from MA Risk Scores

The Biggest Medicare Advantage Payment Change in Years

On January 26, 2026, the Centers for Medicare and Medicaid Services (CMS) released the Calendar Year (CY) 2027 Advance Notice for Medicare Advantage (MA) and Part D. Buried inside a dense actuarial document is a proposal that could reshape how every risk adjustment coder in the country does their work: CMS wants to ban "unlinked" chart reviews from counting toward Risk Adjustment Factor (RAF) scores, starting with payment year 2027.

If finalized -- and the final Rate Announcement is expected in early April 2026 -- this single change would reduce MA plan payments by an estimated 1.53 percent, or more than $7 billion in one year. For Hierarchical Condition Category (HCC) coders, coding managers, and the health plans that employ them, understanding this proposal is not optional. It is urgent.

What Are Unlinked Chart Reviews?

To understand the proposal, you need to understand the two ways diagnosis codes reach CMS for risk adjustment purposes.

Encounter-linked submissions come from actual clinical visits. A patient sees a provider, the provider documents and codes the visit, and those International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes flow through claims to CMS. These diagnoses are tied to a specific date of service, a specific provider, and a face-to-face encounter.

Unlinked chart review records are different. In this workflow, a health plan or its vendor retrospectively reviews a patient's medical records -- often months after the encounter -- looking for diagnosis codes that were documented in the chart but never submitted on a claim. Those codes are then sent to CMS through a Chart Review Record (CRR) submission, often without any direct connection to a new clinical encounter where the condition was actively managed.

CMS considers a chart review "unlinked" when the diagnosis information is not associated with a specific beneficiary encounter. In other words, no one saw the patient specifically for that condition -- the code was found by mining old records.

Why CMS Is Acting Now

This proposal did not appear out of nowhere. It follows years of escalating concern about the role of chart reviews in inflating MA risk scores.

The numbers are staggering. The Medicare Payment Advisory Commission (MedPAC) estimated that chart reviews drove approximately $24 billion in MA overpayments in 2023 alone. In 2022, one in six MA enrollees underwent a chart review that resulted in increased CMS reimbursement to their health plan. Traditional Fee-for-Service (FFS) Medicare does not use chart reviews at all, which means every dollar generated through this practice represents a gap between how MA and FFS Medicare calculate payments.

Enforcement actions have intensified. The Kaiser Permanente $556 million False Claims Act settlement in January 2026, the Aetna settlement in March 2026, and the Office of Inspector General (OIG)'s new Industry Compliance Program Guidance all pointed to chart reviews as a core risk area. CMS has watched these enforcement trends and is now proposing to address the root cause at the payment methodology level.

The V28 model transition created an opening. With CMS completing the three-year phase-in of the CMS-HCC V28 risk adjustment model in 2026 -- meaning risk scores are now calculated 100 percent under V28 -- the agency is already in a period of significant model refinement. Adding a chart review exclusion fits naturally into this broader overhaul.

What the Proposal Would Actually Change

If finalized, the rule would work as follows:

The practical effect is straightforward: if a diagnosis was not addressed during a real visit where a provider saw the patient, it will not generate risk adjustment revenue.

What This Means for HCC Coders

For coders working in risk adjustment, this proposal carries several important implications.

Concurrent coding becomes even more critical. If retrospective chart reviews lose their risk adjustment value, the point of capture shifts entirely to the clinical encounter itself. Coders embedded in real-time or near-real-time workflows -- reviewing documentation while the patient is still in the office or within days of the visit -- become the primary defense against missed HCCs. Organizations that have underinvested in concurrent coding will feel the impact most.

Documentation quality at the point of care matters more than ever. The old safety net of "we will catch it in chart review" disappears under this proposal. Providers must document every active condition with sufficient specificity during the encounter. Coders should be reinforcing the Monitor, Evaluate, Assess/Address, Treat (MEAT) criteria with their provider partners now, before the rule takes effect.

Retrospective chart review teams may shrink or pivot. Organizations that have built large retrospective chart review operations will need to evaluate whether those investments still make sense. Some may redirect those resources toward prospective coding support, provider education, or clinical documentation improvement (CDI) programs that improve capture at the encounter level.

Suspect condition lists need a new strategy. Many MA plans use "suspect lists" -- conditions a patient likely still has based on prior-year data -- to guide chart reviews. Under the new rule, suspect lists would only be useful if they inform the provider before or during the encounter, prompting the provider to address the condition face-to-face. Suspect-to-retrospective-review pipelines would lose their payment impact.

The Bigger Picture: Encounter-Based Risk Adjustment

This proposal is part of a broader CMS philosophy that risk adjustment should reflect what happens during actual patient care, not what can be extracted from historical documentation through administrative processes. Combined with the V28 model's emphasis on greater diagnostic specificity, the exclusion of certain unspecified codes from HCC mapping, and the OIG's compliance guidance warning against chart review abuse, the direction is clear: CMS is building an encounter-based risk adjustment system.

For coders, this is not a reason to panic. It is a reason to double down on the fundamentals that have always defined high-quality HCC coding:

How to Prepare Before April

The final CY 2027 Rate Announcement is expected in early April 2026. While the proposal could be modified based on public comments, CMS has signaled strong intent to move forward. Here is what you can do now:

1. Audit your current chart review workflows. Identify what percentage of your HCC submissions come from unlinked CRRs versus encounter-linked claims. This tells you your exposure.

2. Invest in concurrent coding infrastructure. If your organization relies heavily on retrospective capture, begin shifting resources toward real-time or near-real-time coding support.

3. Educate providers on complete encounter documentation. Every annual wellness visit, every chronic care management appointment, every specialist consult is an opportunity to capture HCCs -- but only if the provider documents the condition with specificity.

4. Review your suspect condition workflows. Ensure suspect lists are reaching providers before encounters, not just chart review teams after the fact.

Stay Current With HCC Buddy

Regulatory changes like this one are exactly why staying current on risk adjustment policy matters. HCC Buddy provides free tools that help coders work accurately at the point of care -- from real-time ICD-10-CM to HCC lookups to RAF score calculations -- so your coding program is built on encounter-level precision, not retrospective corrections.

If you are not already using these tools, create a free account and start building the workflows that will keep your organization compliant no matter what CMS finalizes in April.