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_HCC137 | 0.424 |
| Community, non-dual, disabled | CND_HCC137 | 0.365 |
| Community, full-benefit dual, aged | CFA_HCC137 | 0.502 |
| Community, full-benefit dual, disabled | CFD_HCC137 | 0.471 |
| Community, partial-benefit dual, aged | CPA_HCC137 | 0.394 |
| Community, partial-benefit dual, disabled | CPD_HCC137 | 0.348 |
| Long-term institutional | INS_HCC137 | 0.297 |
Hierarchy
Hierarchical condition categories pay only the most severe manifestation of a disease. When HCC 135 (Drug Use with Psychotic Complications) or HCC 136 (Alcohol Use with Psychotic Complications) is also documented for the same beneficiary, HCC 137 is dropped from the score. When HCC 137 is present it drops 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.
HCC 135
Drug Use with Psychotic Complications · 97 codes · factor 0.424
HCC 136
Alcohol Use with Psychotic Complications · 19 codes · factor 0.424
HCC 138
Drug Use Disorder, Mild, Uncomplicated, Except Cannabis · 14 codes · factor 0.423
HCC 139
Alcohol Use Disorder, Moderate/Severe, or Alcohol Use with Specified Non-Psychotic Complications · 27 codes · factor 0.242
ICD-10-CM codes that map to HCC 137
308 codes map to this category in the PY2027 initial mapping, concentrated in the F19 (38), F13 (35), F14 (35), F15 (35), F11 (32), F16 (27) 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 |
|---|---|
| F11120 | Opioid abuse with intoxication, uncomplicated |
| F11121 | Opioid abuse with intoxication delirium |
| F11122 | Opioid abuse with intoxication with perceptual disturbance |
| F11129 | Opioid abuse with intoxication, unspecified |
| F1113 | Opioid abuse with withdrawal |
| F1114 | Opioid abuse with opioid-induced mood disorder |
| F11181 | Opioid abuse with opioid-induced sexual dysfunction |
| F11182 | Opioid abuse with opioid-induced sleep disorder |
| F11188 | Opioid abuse with other opioid-induced disorder |
| F1119 | Opioid abuse with unspecified opioid-induced disorder |
| F1120 | Opioid dependence, uncomplicated |
| F1121 | Opioid dependence, in remission |
| F11220 | Opioid dependence with intoxication, uncomplicated |
| F11221 | Opioid dependence with intoxication delirium |
| F11222 | Opioid dependence with intoxication with perceptual disturbance |
| F11229 | Opioid dependence with intoxication, unspecified |
| F1123 | Opioid dependence with withdrawal |
| F1124 | Opioid dependence with opioid-induced mood disorder |
| F11281 | Opioid dependence with opioid-induced sexual dysfunction |
| F11282 | Opioid dependence with opioid-induced sleep disorder |
| F11288 | Opioid dependence with other opioid-induced disorder |
| F1129 | Opioid dependence with unspecified opioid-induced disorder |
| F11920 | Opioid use, unspecified with intoxication, uncomplicated |
| F11921 | Opioid use, unspecified with intoxication delirium |
| F11922 | Opioid use, unspecified with intoxication with perceptual disturbance |
| F11929 | Opioid use, unspecified with intoxication, unspecified |
| F1193 | Opioid use, unspecified with withdrawal |
| F1194 | Opioid use, unspecified with opioid-induced mood disorder |
| F11981 | Opioid use, unspecified with opioid-induced sexual dysfunction |
| F11982 | Opioid use, unspecified with opioid-induced sleep disorder |
| F11988 | Opioid use, unspecified with other opioid-induced disorder |
| F1199 | Opioid use, unspecified with unspecified opioid-induced disorder |
| F1213 | Cannabis abuse with withdrawal |
| F12180 | Cannabis abuse with cannabis-induced anxiety disorder |
| F12188 | Cannabis abuse with other cannabis-induced disorder |
| F1220 | Cannabis dependence, uncomplicated |
| F1221 | Cannabis dependence, in remission |
| F12220 | Cannabis dependence with intoxication, uncomplicated |
| F12221 | Cannabis dependence with intoxication delirium |
| F12222 | Cannabis dependence with intoxication with perceptual disturbance |
| F12229 | Cannabis dependence with intoxication, unspecified |
| F1223 | Cannabis dependence with withdrawal |
| F12280 | Cannabis dependence with cannabis-induced anxiety disorder |
| F12288 | Cannabis dependence with other cannabis-induced disorder |
| F1229 | Cannabis dependence with unspecified cannabis-induced disorder |
| F1293 | Cannabis use, unspecified with withdrawal |
| F12980 | Cannabis use, unspecified with anxiety disorder |
| F12988 | Cannabis use, unspecified with other cannabis-induced disorder |
| F13120 | Sedative, hypnotic or anxiolytic abuse with intoxication, uncomplicated |
| F13121 | Sedative, hypnotic or anxiolytic abuse with intoxication delirium |
| F13129 | Sedative, hypnotic or anxiolytic abuse with intoxication, unspecified |
| F13130 | Sedative, hypnotic or anxiolytic abuse with withdrawal, uncomplicated |
| F13139 | Sedative, hypnotic or anxiolytic abuse with withdrawal, unspecified |
| F1314 | Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced mood disorder |
| F13180 | Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced anxiety disorder |
| F13181 | Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sexual dysfunction |
| F13182 | Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sleep disorder |
| F13188 | Sedative, hypnotic or anxiolytic abuse with other sedative, hypnotic or anxiolytic-induced disorder |
| F1319 | Sedative, hypnotic or anxiolytic abuse with unspecified sedative, hypnotic or anxiolytic-induced disorder |
| F1320 | Sedative, hypnotic or anxiolytic dependence, uncomplicated |
| F1321 | Sedative, hypnotic or anxiolytic dependence, in remission |
| F13220 | Sedative, hypnotic or anxiolytic dependence with intoxication, uncomplicated |
| F13221 | Sedative, hypnotic or anxiolytic dependence with intoxication delirium |
| F13229 | Sedative, hypnotic or anxiolytic dependence with intoxication, unspecified |
| F13230 | Sedative, hypnotic or anxiolytic dependence with withdrawal, uncomplicated |
| F13239 | Sedative, hypnotic or anxiolytic dependence with withdrawal, unspecified |
| F1324 | Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced mood disorder |
| F13280 | Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced anxiety disorder |
| F13281 | Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sexual dysfunction |
| F13282 | Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder |
| F13288 | Sedative, hypnotic or anxiolytic dependence with other sedative, hypnotic or anxiolytic-induced disorder |
| F1329 | Sedative, hypnotic or anxiolytic dependence with unspecified sedative, hypnotic or anxiolytic-induced disorder |
| F13920 | Sedative, hypnotic or anxiolytic use, unspecified with intoxication, uncomplicated |
| F13921 | Sedative, hypnotic or anxiolytic use, unspecified with intoxication delirium |
| F13929 | Sedative, hypnotic or anxiolytic use, unspecified with intoxication, unspecified |
| F13930 | Sedative, hypnotic or anxiolytic use, unspecified with withdrawal, uncomplicated |
| F13939 | Sedative, hypnotic or anxiolytic use, unspecified with withdrawal, unspecified |
| F1394 | Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced mood disorder |
| F13980 | Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced anxiety disorder |
| F13981 | Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced sexual dysfunction |
| F13982 | Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced sleep disorder |
| F13988 | Sedative, hypnotic or anxiolytic use, unspecified with other sedative, hypnotic or anxiolytic-induced disorder |
| F1399 | Sedative, hypnotic or anxiolytic use, unspecified with unspecified sedative, hypnotic or anxiolytic-induced disorder |
| F14120 | Cocaine abuse with intoxication, uncomplicated |
| F14121 | Cocaine abuse with intoxication with delirium |
| F14122 | Cocaine abuse with intoxication with perceptual disturbance |
| F14129 | Cocaine abuse with intoxication, unspecified |
| F1413 | Cocaine abuse, unspecified with withdrawal |
| F1414 | Cocaine abuse with cocaine-induced mood disorder |
| F14180 | Cocaine abuse with cocaine-induced anxiety disorder |
| F14181 | Cocaine abuse with cocaine-induced sexual dysfunction |
| F14182 | Cocaine abuse with cocaine-induced sleep disorder |
| F14188 | Cocaine abuse with other cocaine-induced disorder |
| F1419 | Cocaine abuse with unspecified cocaine-induced disorder |
| F1420 | Cocaine dependence, uncomplicated |
| F1421 | Cocaine dependence, in remission |
| F14220 | Cocaine dependence with intoxication, uncomplicated |
| F14221 | Cocaine dependence with intoxication delirium |
| F14222 | Cocaine dependence with intoxication with perceptual disturbance |
| F14229 | Cocaine dependence with intoxication, unspecified |
| F1423 | Cocaine dependence with withdrawal |
| F1424 | Cocaine dependence with cocaine-induced mood disorder |
| F14280 | Cocaine dependence with cocaine-induced anxiety disorder |
| F14281 | Cocaine dependence with cocaine-induced sexual dysfunction |
| F14282 | Cocaine dependence with cocaine-induced sleep disorder |
| F14288 | Cocaine dependence with other cocaine-induced disorder |
| F1429 | Cocaine dependence with unspecified cocaine-induced disorder |
| F14920 | Cocaine use, unspecified with intoxication, uncomplicated |
| F14921 | Cocaine use, unspecified with intoxication delirium |
| F14922 | Cocaine use, unspecified with intoxication with perceptual disturbance |
| F14929 | Cocaine use, unspecified with intoxication, unspecified |
| F1493 | Cocaine use, unspecified with withdrawal |
| F1494 | Cocaine use, unspecified with cocaine-induced mood disorder |
| F14980 | Cocaine use, unspecified with cocaine-induced anxiety disorder |
| F14981 | Cocaine use, unspecified with cocaine-induced sexual dysfunction |
| F14982 | Cocaine use, unspecified with cocaine-induced sleep disorder |
| F14988 | Cocaine use, unspecified with other cocaine-induced disorder |
| F1499 | Cocaine use, unspecified with unspecified cocaine-induced disorder |
| F15120 | Other stimulant abuse with intoxication, uncomplicated |
| F15121 | Other stimulant abuse with intoxication delirium |
| F15122 | Other stimulant abuse with intoxication with perceptual disturbance |
| F15129 | Other stimulant abuse with intoxication, unspecified |
| F1513 | Other stimulant abuse with withdrawal |
| F1514 | Other stimulant abuse with stimulant-induced mood disorder |
| F15180 | Other stimulant abuse with stimulant-induced anxiety disorder |
| F15181 | Other stimulant abuse with stimulant-induced sexual dysfunction |
| F15182 | Other stimulant abuse with stimulant-induced sleep disorder |
| F15188 | Other stimulant abuse with other stimulant-induced disorder |
| F1519 | Other stimulant abuse with unspecified stimulant-induced disorder |
| F1520 | Other stimulant dependence, uncomplicated |
| F1521 | Other stimulant dependence, in remission |
| F15220 | Other stimulant dependence with intoxication, uncomplicated |
| F15221 | Other stimulant dependence with intoxication delirium |
| F15222 | Other stimulant dependence with intoxication with perceptual disturbance |
| F15229 | Other stimulant dependence with intoxication, unspecified |
| F1523 | Other stimulant dependence with withdrawal |
| F1524 | Other stimulant dependence with stimulant-induced mood disorder |
| F15280 | Other stimulant dependence with stimulant-induced anxiety disorder |
| F15281 | Other stimulant dependence with stimulant-induced sexual dysfunction |
| F15282 | Other stimulant dependence with stimulant-induced sleep disorder |
| F15288 | Other stimulant dependence with other stimulant-induced disorder |
| F1529 | Other stimulant dependence with unspecified stimulant-induced disorder |
| F15920 | Other stimulant use, unspecified with intoxication, uncomplicated |
| F15921 | Other stimulant use, unspecified with intoxication delirium |
| F15922 | Other stimulant use, unspecified with intoxication with perceptual disturbance |
| F15929 | Other stimulant use, unspecified with intoxication, unspecified |
| F1593 | Other stimulant use, unspecified with withdrawal |
| F1594 | Other stimulant use, unspecified with stimulant-induced mood disorder |
| F15980 | Other stimulant use, unspecified with stimulant-induced anxiety disorder |
| F15981 | Other stimulant use, unspecified with stimulant-induced sexual dysfunction |
| F15982 | Other stimulant use, unspecified with stimulant-induced sleep disorder |
| F15988 | Other stimulant use, unspecified with other stimulant-induced disorder |
| F1599 | Other stimulant use, unspecified with unspecified stimulant-induced disorder |
| F16120 | Hallucinogen abuse with intoxication, uncomplicated |
| F16121 | Hallucinogen abuse with intoxication with delirium |
| F16122 | Hallucinogen abuse with intoxication with perceptual disturbance |
| F16129 | Hallucinogen abuse with intoxication, unspecified |
| F1614 | Hallucinogen abuse with hallucinogen-induced mood disorder |
| F16180 | Hallucinogen abuse with hallucinogen-induced anxiety disorder |
| F16183 | Hallucinogen abuse with hallucinogen persisting perception disorder (flashbacks) |
| F16188 | Hallucinogen abuse with other hallucinogen-induced disorder |
| F1619 | Hallucinogen abuse with unspecified hallucinogen-induced disorder |
| F1620 | Hallucinogen dependence, uncomplicated |
| F1621 | Hallucinogen dependence, in remission |
| F16220 | Hallucinogen dependence with intoxication, uncomplicated |
| F16221 | Hallucinogen dependence with intoxication with delirium |
| F16229 | Hallucinogen dependence with intoxication, unspecified |
| F1624 | Hallucinogen dependence with hallucinogen-induced mood disorder |
| F16280 | Hallucinogen dependence with hallucinogen-induced anxiety disorder |
| F16283 | Hallucinogen dependence with hallucinogen persisting perception disorder (flashbacks) |
| F16288 | Hallucinogen dependence with other hallucinogen-induced disorder |
| F1629 | Hallucinogen dependence with unspecified hallucinogen-induced disorder |
| F16920 | Hallucinogen use, unspecified with intoxication, uncomplicated |
| F16921 | Hallucinogen use, unspecified with intoxication with delirium |
| F16929 | Hallucinogen use, unspecified with intoxication, unspecified |
| F1694 | Hallucinogen use, unspecified with hallucinogen-induced mood disorder |
| F16980 | Hallucinogen use, unspecified with hallucinogen-induced anxiety disorder |
| F16983 | Hallucinogen use, unspecified with hallucinogen persisting perception disorder (flashbacks) |
| F16988 | Hallucinogen use, unspecified with other hallucinogen-induced disorder |
| F1699 | Hallucinogen use, unspecified with unspecified hallucinogen-induced disorder |
| F18120 | Inhalant abuse with intoxication, uncomplicated |
| F18121 | Inhalant abuse with intoxication delirium |
| F18129 | Inhalant abuse with intoxication, unspecified |
| F1814 | Inhalant abuse with inhalant-induced mood disorder |
| F18180 | Inhalant abuse with inhalant-induced anxiety disorder |
| F18188 | Inhalant abuse with other inhalant-induced disorder |
| F1819 | Inhalant abuse with unspecified inhalant-induced disorder |
| F1820 | Inhalant dependence, uncomplicated |
| F1821 | Inhalant dependence, in remission |
| F18220 | Inhalant dependence with intoxication, uncomplicated |
| F18221 | Inhalant dependence with intoxication delirium |
| F18229 | Inhalant dependence with intoxication, unspecified |
| F1824 | Inhalant dependence with inhalant-induced mood disorder |
| F18280 | Inhalant dependence with inhalant-induced anxiety disorder |
| F18288 | Inhalant dependence with other inhalant-induced disorder |
| F1829 | Inhalant dependence with unspecified inhalant-induced disorder |
| F18920 | Inhalant use, unspecified with intoxication, uncomplicated |
| F18921 | Inhalant use, unspecified with intoxication with delirium |
| F18929 | Inhalant use, unspecified with intoxication, unspecified |
| F1894 | Inhalant use, unspecified with inhalant-induced mood disorder |
| F18980 | Inhalant use, unspecified with inhalant-induced anxiety disorder |
| F18988 | Inhalant use, unspecified with other inhalant-induced disorder |
| F1899 | Inhalant use, unspecified with unspecified inhalant-induced disorder |
| F19120 | Other psychoactive substance abuse with intoxication, uncomplicated |
| F19121 | Other psychoactive substance abuse with intoxication delirium |
| F19122 | Other psychoactive substance abuse with intoxication with perceptual disturbances |
| F19129 | Other psychoactive substance abuse with intoxication, unspecified |
| F19130 | Other psychoactive substance abuse with withdrawal, uncomplicated |
| F19139 | Other psychoactive substance abuse with withdrawal, unspecified |
| F1914 | Other psychoactive substance abuse with psychoactive substance-induced mood disorder |
| F19180 | Other psychoactive substance abuse with psychoactive substance-induced anxiety disorder |
| F19181 | Other psychoactive substance abuse with psychoactive substance-induced sexual dysfunction |
| F19182 | Other psychoactive substance abuse with psychoactive substance-induced sleep disorder |
| F19188 | Other psychoactive substance abuse with other psychoactive substance-induced disorder |
| F1919 | Other psychoactive substance abuse with unspecified psychoactive substance-induced disorder |
| F1920 | Other psychoactive substance dependence, uncomplicated |
| F1921 | Other psychoactive substance dependence, in remission |
| F19220 | Other psychoactive substance dependence with intoxication, uncomplicated |
| F19221 | Other psychoactive substance dependence with intoxication delirium |
| F19222 | Other psychoactive substance dependence with intoxication with perceptual disturbance |
| F19229 | Other psychoactive substance dependence with intoxication, unspecified |
| F19230 | Other psychoactive substance dependence with withdrawal, uncomplicated |
| F19239 | Other psychoactive substance dependence with withdrawal, unspecified |
| F1924 | Other psychoactive substance dependence with psychoactive substance-induced mood disorder |
| F19280 | Other psychoactive substance dependence with psychoactive substance-induced anxiety disorder |
| F19281 | Other psychoactive substance dependence with psychoactive substance-induced sexual dysfunction |
| F19282 | Other psychoactive substance dependence with psychoactive substance-induced sleep disorder |
| F19288 | Other psychoactive substance dependence with other psychoactive substance-induced disorder |
| F1929 | Other psychoactive substance dependence with unspecified psychoactive substance-induced disorder |
| F19920 | Other psychoactive substance use, unspecified with intoxication, uncomplicated |
| F19921 | Other psychoactive substance use, unspecified with intoxication with delirium |
| F19922 | Other psychoactive substance use, unspecified with intoxication with perceptual disturbance |
| F19929 | Other psychoactive substance use, unspecified with intoxication, unspecified |
| F19930 | Other psychoactive substance use, unspecified with withdrawal, uncomplicated |
| F19939 | Other psychoactive substance use, unspecified with withdrawal, unspecified |
| F1994 | Other psychoactive substance use, unspecified with psychoactive substance-induced mood disorder |
| F19980 | Other psychoactive substance use, unspecified with psychoactive substance-induced anxiety disorder |
| F19981 | Other psychoactive substance use, unspecified with psychoactive substance-induced sexual dysfunction |
| F19982 | Other psychoactive substance use, unspecified with psychoactive substance-induced sleep disorder |
| F19988 | Other psychoactive substance use, unspecified with other psychoactive substance-induced disorder |
| F1999 | Other psychoactive substance use, unspecified with unspecified psychoactive substance-induced disorder |
| P040 | Newborn affected by maternal anesthesia and analgesia in pregnancy, labor and delivery |
| P0411 | Newborn affected by maternal antineoplastic chemotherapy |
| P0412 | Newborn affected by maternal cytotoxic drugs |
| P0413 | Newborn affected by maternal use of anticonvulsants |
| P0414 | Newborn affected by maternal use of opiates |
| P0415 | Newborn affected by maternal use of antidepressants |
| P0416 | Newborn affected by maternal use of amphetamines |
| P0417 | Newborn affected by maternal use of sedative-hypnotics |
| P0418 | Newborn affected by other maternal medication |
| P0419 | Newborn affected by maternal use of unspecified medication |
| P041A | Newborn affected by maternal use of anxiolytics |
| P042 | Newborn affected by maternal use of tobacco |
| P043 | Newborn affected by maternal use of alcohol |
| P0440 | Newborn affected by maternal use of unspecified drugs of addiction |
| P0441 | Newborn affected by maternal use of cocaine |
| P0442 | Newborn affected by maternal use of hallucinogens |
| P0449 | Newborn affected by maternal use of other drugs of addiction |
| P045 | Newborn affected by maternal use of nutritional chemical substances |
| P046 | Newborn affected by maternal exposure to environmental chemical substances |
| P0481 | Newborn affected by maternal use of cannabis |
| P0489 | Newborn affected by other maternal noxious substances |
| P049 | Newborn affected by maternal noxious substance, unspecified |
| P930 | Grey baby syndrome |
| P938 | Other reactions and intoxications due to drugs administered to newborn |
| P961 | Neonatal withdrawal symptoms from maternal use of drugs of addiction |
| P962 | Withdrawal symptoms from therapeutic use of drugs in newborn |
| R1116 | Cannabis hyperemesis syndrome |
| T400X1A | Poisoning by opium, accidental (unintentional), initial encounter |
| T400X4A | Poisoning by opium, undetermined, initial encounter |
| T401X1A | Poisoning by heroin, accidental (unintentional), initial encounter |
| T401X4A | Poisoning by heroin, undetermined, initial encounter |
| T402X1A | Poisoning by other opioids, accidental (unintentional), initial encounter |
| T402X4A | Poisoning by other opioids, undetermined, initial encounter |
| T403X1A | Poisoning by methadone, accidental (unintentional), initial encounter |
| T403X4A | Poisoning by methadone, undetermined, initial encounter |
| T40411A | Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), initial encounter |
| T40414A | Poisoning by fentanyl or fentanyl analogs, undetermined, initial encounter |
| T40421A | Poisoning by tramadol, accidental (unintentional), initial encounter |
| T40424A | Poisoning by tramadol, undetermined, initial encounter |
| T40491A | Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter |
| T40494A | Poisoning by other synthetic narcotics, undetermined, initial encounter |
| T405X1A | Poisoning by cocaine, accidental (unintentional), initial encounter |
| T405X4A | Poisoning by cocaine, undetermined, initial encounter |
| T40601A | Poisoning by unspecified narcotics, accidental (unintentional), initial encounter |
| T40604A | Poisoning by unspecified narcotics, undetermined, initial encounter |
| T40691A | Poisoning by other narcotics, accidental (unintentional), initial encounter |
| T40694A | Poisoning by other narcotics, undetermined, initial encounter |
| T408X1A | Poisoning by lysergide [LSD], accidental (unintentional), initial encounter |
| T408X4A | Poisoning by lysergide [LSD], undetermined, initial encounter |
| T40901A | Poisoning by unspecified psychodysleptics [hallucinogens], accidental (unintentional), initial encounter |
| T40904A | Poisoning by unspecified psychodysleptics [hallucinogens], undetermined, initial encounter |
| T40991A | Poisoning by other psychodysleptics [hallucinogens], accidental (unintentional), initial encounter |
| T40994A | Poisoning by other psychodysleptics [hallucinogens], undetermined, initial encounter |
| T43601A | Poisoning by unspecified psychostimulants, accidental (unintentional), initial encounter |
| T43604A | Poisoning by unspecified psychostimulants, undetermined, initial encounter |
| T43611A | Poisoning by caffeine, accidental (unintentional), initial encounter |
| T43614A | Poisoning by caffeine, undetermined, initial encounter |
| T43621A | Poisoning by amphetamines, accidental (unintentional), initial encounter |
| T43624A | Poisoning by amphetamines, undetermined, initial encounter |
| T43631A | Poisoning by methylphenidate, accidental (unintentional), initial encounter |
| T43634A | Poisoning by methylphenidate, undetermined, initial encounter |
| T43641A | Poisoning by ecstasy, accidental (unintentional), initial encounter |
| T43644A | Poisoning by ecstasy, undetermined, initial encounter |
| T43651A | Poisoning by methamphetamines accidental (unintentional), initial encounter |
| T43654A | Poisoning by methamphetamines, undetermined, initial encounter |
| T43691A | Poisoning by other psychostimulants, accidental (unintentional), initial encounter |
| T43694A | Poisoning by other psychostimulants, undetermined, initial encounter |
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 |
|---|---|
| 55 | 242 |
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 137?
308 ICD-10-CM codes map to HCC 137 in the CMS PY2027 initial mapping, for example F11120 Opioid abuse with intoxication, uncomplicated; F11121 Opioid abuse with intoxication delirium; F11122 Opioid abuse with intoxication with perceptual disturbance; F11129 Opioid abuse with intoxication, unspecified. 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 137 add to a risk score?
The V28 relative factor for HCC 137 is 0.424 for a community, non-dual, aged beneficiary, 0.502 for full-benefit dual aged, 0.365 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 137 count together with related categories?
No. Within a hierarchy only the most severe category is paid. HCC 137 is dropped when HCC 135 (Drug Use with Psychotic Complications) or HCC 136 (Alcohol Use with Psychotic Complications) is also present, and it drops HCC 138, HCC 139 when it is present.
What has to be documented for HCC 137 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.