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_HCC138 | 0.423 |
| Community, non-dual, disabled | CND_HCC138 | 0.264 |
| Community, full-benefit dual, aged | CFA_HCC138 | 0.502 |
| Community, full-benefit dual, disabled | CFD_HCC138 | 0.384 |
| Community, partial-benefit dual, aged | CPA_HCC138 | 0.355 |
| Community, partial-benefit dual, disabled | CPD_HCC138 | 0.348 |
| Long-term institutional | INS_HCC138 | 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) or HCC 137 (Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications) is also documented for the same beneficiary, HCC 138 is dropped from the score. When HCC 138 is present it drops 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 138
14 codes map to this category in the PY2027 initial mapping, concentrated in the F11 (2), F13 (2), F14 (2), F15 (2), F16 (2), F18 (2) 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 |
|---|---|
| F1110 | Opioid abuse, uncomplicated |
| F1111 | Opioid abuse, in remission |
| F1310 | Sedative, hypnotic or anxiolytic abuse, uncomplicated |
| F1311 | Sedative, hypnotic or anxiolytic abuse, in remission |
| F1410 | Cocaine abuse, uncomplicated |
| F1411 | Cocaine abuse, in remission |
| F1510 | Other stimulant abuse, uncomplicated |
| F1511 | Other stimulant abuse, in remission |
| F1610 | Hallucinogen abuse, uncomplicated |
| F1611 | Hallucinogen abuse, in remission |
| F1810 | Inhalant abuse, uncomplicated |
| F1811 | Inhalant abuse, in remission |
| F1910 | Other psychoactive substance abuse, uncomplicated |
| F1911 | Other psychoactive substance abuse, in remission |
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 138?
14 ICD-10-CM codes map to HCC 138 in the CMS PY2027 initial mapping, for example F1110 Opioid abuse, uncomplicated; F1111 Opioid abuse, in remission; F1310 Sedative, hypnotic or anxiolytic abuse, uncomplicated; F1311 Sedative, hypnotic or anxiolytic abuse, in remission. 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 138 add to a risk score?
The V28 relative factor for HCC 138 is 0.423 for a community, non-dual, aged beneficiary, 0.502 for full-benefit dual aged, 0.264 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 138 count together with related categories?
No. Within a hierarchy only the most severe category is paid. HCC 138 is dropped when HCC 135 (Drug Use with Psychotic Complications) or HCC 136 (Alcohol Use with Psychotic Complications) or HCC 137 (Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications) is also present, and it drops HCC 139 when it is present.
What has to be documented for HCC 138 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.