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_HCC213 | 0.370 |
| Community, non-dual, disabled | CND_HCC213 | 0.510 |
| Community, full-benefit dual, aged | CFA_HCC213 | 0.573 |
| Community, full-benefit dual, disabled | CFD_HCC213 | 0.662 |
| Community, partial-benefit dual, aged | CPA_HCC213 | 0.409 |
| Community, partial-benefit dual, disabled | CPD_HCC213 | 0.493 |
| Long-term institutional | INS_HCC213 | 0.258 |
Hierarchy
Hierarchical condition categories pay only the most severe manifestation of a disease. When HCC 211 (Respirator Dependence/Tracheostomy Status/Complications) or HCC 212 (Respiratory Arrest) is also documented for the same beneficiary, HCC 213 is dropped from the score.
ICD-10-CM codes that map to HCC 213
36 codes map to this category in the PY2027 initial mapping, concentrated in the J96 (12), P28 (5), P26 (4), P27 (4), I46 (3), I49 (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 |
|---|---|
| I462 | Cardiac arrest due to underlying cardiac condition |
| I468 | Cardiac arrest due to other underlying condition |
| I469 | Cardiac arrest, cause unspecified |
| I4901 | Ventricular fibrillation |
| I4902 | Ventricular flutter |
| J80 | Acute respiratory distress syndrome |
| J810 | Acute pulmonary edema |
| J9600 | Acute respiratory failure, unspecified whether with hypoxia or hypercapnia |
| J9601 | Acute respiratory failure with hypoxia |
| J9602 | Acute respiratory failure with hypercapnia |
| J9610 | Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia |
| J9611 | Chronic respiratory failure with hypoxia |
| J9612 | Chronic respiratory failure with hypercapnia |
| J9620 | Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia |
| J9621 | Acute and chronic respiratory failure with hypoxia |
| J9622 | Acute and chronic respiratory failure with hypercapnia |
| J9690 | Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia |
| J9691 | Respiratory failure, unspecified with hypoxia |
| J9692 | Respiratory failure, unspecified with hypercapnia |
| P220 | Respiratory distress syndrome of newborn |
| P260 | Tracheobronchial hemorrhage originating in the perinatal period |
| P261 | Massive pulmonary hemorrhage originating in the perinatal period |
| P268 | Other pulmonary hemorrhages originating in the perinatal period |
| P269 | Unspecified pulmonary hemorrhage originating in the perinatal period |
| P270 | Wilson-Mikity syndrome |
| P271 | Bronchopulmonary dysplasia originating in the perinatal period |
| P278 | Other chronic respiratory diseases originating in the perinatal period |
| P279 | Unspecified chronic respiratory disease originating in the perinatal period |
| P280 | Primary atelectasis of newborn |
| P2810 | Unspecified atelectasis of newborn |
| P2811 | Resorption atelectasis without respiratory distress syndrome |
| P2819 | Other atelectasis of newborn |
| P285 | Respiratory failure of newborn |
| P2981 | Cardiac arrest of newborn |
| R570 | Cardiogenic shock |
| R579 | Shock, unspecified |
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 |
|---|---|
| 84 | 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 213?
36 ICD-10-CM codes map to HCC 213 in the CMS PY2027 initial mapping, for example I462 Cardiac arrest due to underlying cardiac condition; I468 Cardiac arrest due to other underlying condition; I469 Cardiac arrest, cause unspecified; I4901 Ventricular fibrillation. 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 213 add to a risk score?
The V28 relative factor for HCC 213 is 0.370 for a community, non-dual, aged beneficiary, 0.573 for full-benefit dual aged, 0.510 for non-dual disabled and 0.258 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 213 count together with related categories?
No. Within a hierarchy only the most severe category is paid. HCC 213 is dropped when HCC 211 (Respirator Dependence/Tracheostomy Status/Complications) or HCC 212 (Respiratory Arrest) is also present.
What has to be documented for HCC 213 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.