CMS Is Tightening the Rules on Medicare Advantage Chart Reviews. What Providers Need to Know Before 2027

The 2027 risk-adjustment changes put new emphasis on diagnoses that can be traced to qualifying encounters and supporting documentation — even though the rule itself isn’t aimed at providers.

Let’s clear something up first, because the headline version of this story tends to overshoot: CMS is not banning chart reviews. Medicare Advantage organizations can still comb through medical records looking for diagnoses that never made it onto a claim. What’s changing, starting with 2026 dates of service and affecting risk-adjusted payments for 2027, is narrower and more specific — CMS finalized a policy to exclude diagnoses from unlinked chart review records (CRRs) from MA risk-score calculations, meaning diagnoses that can’t be tied back to an actual clinical encounter. There’s one carve-out: beneficiaries who switch from one MA organization to another, since a new plan typically has no way to see the encounter records behind an old plan’s chart review anyway.

One important distinction worth sitting with: this policy applies to how Medicare Advantage organizations calculate risk scores. It doesn’t prohibit chart reviews, and it doesn’t create a blanket new rule that every diagnosis must originate from a provider claim. The rule is directed at MA organizations, not providers. But its practical message for providers and coding teams is worth taking seriously anyway — because it’s a documentation signal, not just a plan-level accounting change.