Relative factors by segment
Each segment is a separate regression; the factor is added to the beneficiary's demographic factors and other categories, then normalized and reduced by the coding intensity adjustment before it meets the plan's base rate. A factor of 1.000 equals the expected cost of an average beneficiary.
| Segment | Model code | Relative factor |
|---|---|---|
| Community, non-dual, aged | CNA_HCC135 | 0.424 |
| Community, non-dual, disabled | CND_HCC135 | 0.637 |
| Community, full-benefit dual, aged | CFA_HCC135 | 0.702 |
| Community, full-benefit dual, disabled | CFD_HCC135 | 1.181 |
| Community, partial-benefit dual, aged | CPA_HCC135 | 0.522 |
| Community, partial-benefit dual, disabled | CPD_HCC135 | 0.922 |
| Long-term institutional | INS_HCC135 | 0.297 |
Hierarchy
Hierarchical condition categories pay only the most severe manifestation of a disease. HCC 135 is the most severe category in its hierarchy. When HCC 135 is present it drops HCC 136 (Alcohol Use with Psychotic Complications), HCC 137 (Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications), HCC 138 (Drug Use Disorder, Mild, Uncomplicated, Except Cannabis), HCC 139 (Alcohol Use Disorder, Moderate/Severe, or Alcohol Use with Specified Non-Psychotic Complications), so documenting the less severe condition alongside it adds nothing to payment but still matters for the clinical record.
ICD-10-CM codes that map to HCC 135
97 codes map to this category in the PY2027 initial mapping, concentrated in the F19 (21), F13 (19), F18 (12), F11 (9), F12 (9), F14 (9) code families. Descriptions are the CMS mapping descriptions for the FY2026 code set; a code that is deleted or split in the October code update stays valid for dates of service before the change.
| ICD-10-CM | Description |
|---|---|
| F11150 | Opioid abuse with opioid-induced psychotic disorder with delusions |
| F11151 | Opioid abuse with opioid-induced psychotic disorder with hallucinations |
| F11159 | Opioid abuse with opioid-induced psychotic disorder, unspecified |
| F11250 | Opioid dependence with opioid-induced psychotic disorder with delusions |
| F11251 | Opioid dependence with opioid-induced psychotic disorder with hallucinations |
| F11259 | Opioid dependence with opioid-induced psychotic disorder, unspecified |
| F11950 | Opioid use, unspecified with opioid-induced psychotic disorder with delusions |
| F11951 | Opioid use, unspecified with opioid-induced psychotic disorder with hallucinations |
| F11959 | Opioid use, unspecified with opioid-induced psychotic disorder, unspecified |
| F12150 | Cannabis abuse with psychotic disorder with delusions |
| F12151 | Cannabis abuse with psychotic disorder with hallucinations |
| F12159 | Cannabis abuse with psychotic disorder, unspecified |
| F12250 | Cannabis dependence with psychotic disorder with delusions |
| F12251 | Cannabis dependence with psychotic disorder with hallucinations |
| F12259 | Cannabis dependence with psychotic disorder, unspecified |
| F12950 | Cannabis use, unspecified with psychotic disorder with delusions |
| F12951 | Cannabis use, unspecified with psychotic disorder with hallucinations |
| F12959 | Cannabis use, unspecified with psychotic disorder, unspecified |
| F13131 | Sedative, hypnotic or anxiolytic abuse with withdrawal delirium |
| F13132 | Sedative, hypnotic or anxiolytic abuse with withdrawal with perceptual disturbance |
| F13150 | Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic disorder with delusions |
| F13151 | Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic disorder with hallucinations |
| F13159 | Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic disorder, unspecified |
| F13231 | Sedative, hypnotic or anxiolytic dependence with withdrawal delirium |
| F13232 | Sedative, hypnotic or anxiolytic dependence with withdrawal with perceptual disturbance |
| F13250 | Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with delusions |
| F13251 | Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with hallucinations |
| F13259 | Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder, unspecified |
| F1326 | Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting amnestic disorder |
| F1327 | Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting dementia |
| F13931 | Sedative, hypnotic or anxiolytic use, unspecified with withdrawal delirium |
| F13932 | Sedative, hypnotic or anxiolytic use, unspecified with withdrawal with perceptual disturbances |
| F13950 | Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced psychotic disorder with delusions |
| F13951 | Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced psychotic disorder with hallucinations |
| F13959 | Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced psychotic disorder, unspecified |
| F1396 | Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced persisting amnestic disorder |
| F1397 | Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced persisting dementia |
| F14150 | Cocaine abuse with cocaine-induced psychotic disorder with delusions |
| F14151 | Cocaine abuse with cocaine-induced psychotic disorder with hallucinations |
| F14159 | Cocaine abuse with cocaine-induced psychotic disorder, unspecified |
| F14250 | Cocaine dependence with cocaine-induced psychotic disorder with delusions |
| F14251 | Cocaine dependence with cocaine-induced psychotic disorder with hallucinations |
| F14259 | Cocaine dependence with cocaine-induced psychotic disorder, unspecified |
| F14950 | Cocaine use, unspecified with cocaine-induced psychotic disorder with delusions |
| F14951 | Cocaine use, unspecified with cocaine-induced psychotic disorder with hallucinations |
| F14959 | Cocaine use, unspecified with cocaine-induced psychotic disorder, unspecified |
| F15150 | Other stimulant abuse with stimulant-induced psychotic disorder with delusions |
| F15151 | Other stimulant abuse with stimulant-induced psychotic disorder with hallucinations |
| F15159 | Other stimulant abuse with stimulant-induced psychotic disorder, unspecified |
| F15250 | Other stimulant dependence with stimulant-induced psychotic disorder with delusions |
| F15251 | Other stimulant dependence with stimulant-induced psychotic disorder with hallucinations |
| F15259 | Other stimulant dependence with stimulant-induced psychotic disorder, unspecified |
| F15950 | Other stimulant use, unspecified with stimulant-induced psychotic disorder with delusions |
| F15951 | Other stimulant use, unspecified with stimulant-induced psychotic disorder with hallucinations |
| F15959 | Other stimulant use, unspecified with stimulant-induced psychotic disorder, unspecified |
| F16150 | Hallucinogen abuse with hallucinogen-induced psychotic disorder with delusions |
| F16151 | Hallucinogen abuse with hallucinogen-induced psychotic disorder with hallucinations |
| F16159 | Hallucinogen abuse with hallucinogen-induced psychotic disorder, unspecified |
| F16250 | Hallucinogen dependence with hallucinogen-induced psychotic disorder with delusions |
| F16251 | Hallucinogen dependence with hallucinogen-induced psychotic disorder with hallucinations |
| F16259 | Hallucinogen dependence with hallucinogen-induced psychotic disorder, unspecified |
| F16950 | Hallucinogen use, unspecified with hallucinogen-induced psychotic disorder with delusions |
| F16951 | Hallucinogen use, unspecified with hallucinogen-induced psychotic disorder with hallucinations |
| F16959 | Hallucinogen use, unspecified with hallucinogen-induced psychotic disorder, unspecified |
| F18150 | Inhalant abuse with inhalant-induced psychotic disorder with delusions |
| F18151 | Inhalant abuse with inhalant-induced psychotic disorder with hallucinations |
| F18159 | Inhalant abuse with inhalant-induced psychotic disorder, unspecified |
| F1817 | Inhalant abuse with inhalant-induced dementia |
| F18250 | Inhalant dependence with inhalant-induced psychotic disorder with delusions |
| F18251 | Inhalant dependence with inhalant-induced psychotic disorder with hallucinations |
| F18259 | Inhalant dependence with inhalant-induced psychotic disorder, unspecified |
| F1827 | Inhalant dependence with inhalant-induced dementia |
| F18950 | Inhalant use, unspecified with inhalant-induced psychotic disorder with delusions |
| F18951 | Inhalant use, unspecified with inhalant-induced psychotic disorder with hallucinations |
| F18959 | Inhalant use, unspecified with inhalant-induced psychotic disorder, unspecified |
| F1897 | Inhalant use, unspecified with inhalant-induced persisting dementia |
| F19131 | Other psychoactive substance abuse with withdrawal delirium |
| F19132 | Other psychoactive substance abuse with withdrawal with perceptual disturbance |
| F19150 | Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with delusions |
| F19151 | Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with hallucinations |
| F19159 | Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder, unspecified |
| F1916 | Other psychoactive substance abuse with psychoactive substance-induced persisting amnestic disorder |
| F1917 | Other psychoactive substance abuse with psychoactive substance-induced persisting dementia |
| F19231 | Other psychoactive substance dependence with withdrawal delirium |
| F19232 | Other psychoactive substance dependence with withdrawal with perceptual disturbance |
| F19250 | Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with delusions |
| F19251 | Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with hallucinations |
| F19259 | Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder, unspecified |
| F1926 | Other psychoactive substance dependence with psychoactive substance-induced persisting amnestic disorder |
| F1927 | Other psychoactive substance dependence with psychoactive substance-induced persisting dementia |
| F19931 | Other psychoactive substance use, unspecified with withdrawal delirium |
| F19932 | Other psychoactive substance use, unspecified with withdrawal with perceptual disturbance |
| F19950 | Other psychoactive substance use, unspecified with psychoactive substance-induced psychotic disorder with delusions |
| F19951 | Other psychoactive substance use, unspecified with psychoactive substance-induced psychotic disorder with hallucinations |
| F19959 | Other psychoactive substance use, unspecified with psychoactive substance-induced psychotic disorder, unspecified |
| F1996 | Other psychoactive substance use, unspecified with psychoactive substance-induced persisting amnestic disorder |
| F1997 | Other psychoactive substance use, unspecified with psychoactive substance-induced persisting dementia |
Where these codes sat in the V22 model
The V28 recalibration renumbered and regrouped categories; this table shows which legacy V22 categories the same ICD-10 codes belonged to, which is the quickest way to reconcile a V22-era HCC gap list with the current model.
| V22 HCC | Codes |
|---|---|
| 54 | 97 |
Capturing and defending the category
A category counts for a payment year when a mapped diagnosis is documented at least once during the data collection year by an acceptable provider type at a face-to-face or audio-video encounter, and when the note shows the condition was monitored, evaluated, assessed or treated. Chronic conditions do not carry forward: a category that is not re-documented in the year drops out of the score, which is why annual wellness visits and problem-list reconciliation are where most recapture happens. Risk adjustment data validation audits sample enrollees and ask for the medical record behind each submitted category; an unsupported category is removed and, under the extrapolation rules, the error rate is applied across the contract. The QuickIntell risk adjustment product surfaces suspected and unsupported categories from the chart, and the HCC hub lists every V28 category with its factor and code count.
Frequently asked questions
Which ICD-10 codes map to HCC 135?
97 ICD-10-CM codes map to HCC 135 in the CMS PY2027 initial mapping, for example F11150 Opioid abuse with opioid-induced psychotic disorder with delusions; F11151 Opioid abuse with opioid-induced psychotic disorder with hallucinations; F11159 Opioid abuse with opioid-induced psychotic disorder, unspecified; F11250 Opioid dependence with opioid-induced psychotic disorder with delusions. The full list is on this page; a code counts only when it is documented at a face-to-face or video encounter in the data collection year and supported by the record.
How much does HCC 135 add to a risk score?
The V28 relative factor for HCC 135 is 0.424 for a community, non-dual, aged beneficiary, 0.702 for full-benefit dual aged, 0.637 for non-dual disabled and 0.297 for long-term institutional members. A factor of 1.000 equals the expected annual cost of an average beneficiary, so the category's share of the payment follows the plan's base rate for that segment.
Does HCC 135 count together with related categories?
No. Within a hierarchy only the most severe category is paid. HCC 135 is the most severe category in its hierarchy, and it drops HCC 136, HCC 137, HCC 138, HCC 139 when it is present.
What has to be documented for HCC 135 to be valid?
The diagnosis must be recorded by an acceptable provider type during a face-to-face or audio-video encounter in the service year, with the note showing that the condition was monitored, evaluated, assessed or treated. Risk adjustment data validation audits recover payment for categories the record does not support, so the code on the claim and the assessment in the note must match.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- ICD-10-CM to CMS-HCC V28 mappings, payment year 2027 initialVersion PY2027 initial ICD-10-CM mappings (dates of service 2026) · effective 2027-01-01 · file 2027 Initial ICD-10-CM Mappings.csvSHA-256 9c260b06d0dd2806…
- CMS-HCC V28 model software: labels, hierarchies and relative factorsVersion CMS-HCC V28 software V2826.115.T2 (PY2027 initial) · effective 2027-01-01 · file C2824T2N.csvSHA-256 20f38d537493b41c…
Disclaimer
Relative factors and mappings are reproduced from the CMS risk adjustment model files as an operational reference. Payment depends on the plan's base rate, normalization, the coding intensity adjustment and the enrollee's segment. Not legal, clinical or billing advice.