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_HCC197 | 0.426 |
| Community, non-dual, disabled | CND_HCC197 | 0.632 |
| Community, full-benefit dual, aged | CFA_HCC197 | 0.369 |
| Community, full-benefit dual, disabled | CFD_HCC197 | 0.681 |
| Community, partial-benefit dual, aged | CPA_HCC197 | 0.162 |
| Community, partial-benefit dual, disabled | CPD_HCC197 | 0.145 |
| Long-term institutional | INS_HCC197 | 0.292 |
Hierarchy
HCC 197 is not part of a hierarchy: it is paid whenever a mapped diagnosis is documented, independently of the beneficiary's other categories.
ICD-10-CM codes that map to HCC 197
21 codes map to this category in the PY2027 initial mapping. 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 |
|---|---|
| G7100 | Muscular dystrophy, unspecified |
| G7101 | Duchenne or Becker muscular dystrophy |
| G7102 | Facioscapulohumeral muscular dystrophy |
| G71031 | Autosomal dominant limb girdle muscular dystrophy |
| G71032 | Autosomal recessive limb girdle muscular dystrophy due to calpain-3 dysfunction |
| G71033 | Limb girdle muscular dystrophy due to dysferlin dysfunction |
| G710340 | Limb girdle muscular dystrophy due to sarcoglycan dysfunction, unspecified |
| G710341 | Limb girdle muscular dystrophy due to alpha sarcoglycan dysfunction |
| G710342 | Limb girdle muscular dystrophy due to beta sarcoglycan dysfunction |
| G710349 | Limb girdle muscular dystrophy due to other sarcoglycan dysfunction |
| G71035 | Limb girdle muscular dystrophy due to anoctamin-5 dysfunction |
| G71036 | Limb girdle muscular dystrophy due to fukutin related protein dysfunction |
| G71038 | Other limb girdle muscular dystrophy |
| G71039 | Limb girdle muscular dystrophy, unspecified |
| G7109 | Other specified muscular dystrophies |
| G7111 | Myotonic muscular dystrophy |
| G7120 | Congenital myopathy, unspecified |
| G7121 | Nemaline myopathy |
| G71220 | X-linked myotubular myopathy |
| G71228 | Other centronuclear myopathy |
| G7129 | Other congenital myopathy |
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 |
|---|---|
| 76 | 21 |
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 197?
21 ICD-10-CM codes map to HCC 197 in the CMS PY2027 initial mapping, for example G7100 Muscular dystrophy, unspecified; G7101 Duchenne or Becker muscular dystrophy; G7102 Facioscapulohumeral muscular dystrophy; G71031 Autosomal dominant limb girdle muscular dystrophy. 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 197 add to a risk score?
The V28 relative factor for HCC 197 is 0.426 for a community, non-dual, aged beneficiary, 0.369 for full-benefit dual aged, 0.632 for non-dual disabled and 0.292 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 197 count together with related categories?
HCC 197 is not part of a hierarchy, so it is paid whenever it is documented regardless of which other categories the beneficiary has.
What has to be documented for HCC 197 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.