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_HCC23 | 0.186 |
| Community, non-dual, disabled | CND_HCC23 | 0.233 |
| Community, full-benefit dual, aged | CFA_HCC23 | 0.196 |
| Community, full-benefit dual, disabled | CFD_HCC23 | 0.218 |
| Community, partial-benefit dual, aged | CPA_HCC23 | 0.203 |
| Community, partial-benefit dual, disabled | CPD_HCC23 | 0.237 |
| Long-term institutional | INS_HCC23 | 0.197 |
Hierarchy
Hierarchical condition categories pay only the most severe manifestation of a disease. When HCC 17 (Cancer Metastatic to Lung, Liver, Brain, and Other Organs; Acute Myeloid Leukemia Except Promyelocytic) or HCC 18 (Cancer Metastatic to Bone, Other and Unspecified Metastatic Cancer; Acute Leukemia Except Myeloid) or HCC 19 (Myelodysplastic Syndromes, Multiple Myeloma, and Other Cancers) or HCC 20 (Lung and Other Severe Cancers) or HCC 21 (Lymphoma and Other Cancers) or HCC 22 (Bladder, Colorectal, and Other Cancers) is also documented for the same beneficiary, HCC 23 is dropped from the score.
ICD-10-CM codes that map to HCC 23
234 codes map to this category in the PY2027 initial mapping, concentrated in the C50 (57), C69 (27), C43 (24), D03 (23), C76 (11), Q85 (11) 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 |
|---|---|
| C430 | Malignant melanoma of lip |
| C4310 | Malignant melanoma of unspecified eyelid, including canthus |
| C43111 | Malignant melanoma of right upper eyelid, including canthus |
| C43112 | Malignant melanoma of right lower eyelid, including canthus |
| C43121 | Malignant melanoma of left upper eyelid, including canthus |
| C43122 | Malignant melanoma of left lower eyelid, including canthus |
| C4320 | Malignant melanoma of unspecified ear and external auricular canal |
| C4321 | Malignant melanoma of right ear and external auricular canal |
| C4322 | Malignant melanoma of left ear and external auricular canal |
| C4330 | Malignant melanoma of unspecified part of face |
| C4331 | Malignant melanoma of nose |
| C4339 | Malignant melanoma of other parts of face |
| C434 | Malignant melanoma of scalp and neck |
| C4351 | Malignant melanoma of anal skin |
| C4352 | Malignant melanoma of skin of breast |
| C4359 | Malignant melanoma of other part of trunk |
| C4360 | Malignant melanoma of unspecified upper limb, including shoulder |
| C4361 | Malignant melanoma of right upper limb, including shoulder |
| C4362 | Malignant melanoma of left upper limb, including shoulder |
| C4370 | Malignant melanoma of unspecified lower limb, including hip |
| C4371 | Malignant melanoma of right lower limb, including hip |
| C4372 | Malignant melanoma of left lower limb, including hip |
| C438 | Malignant melanoma of overlapping sites of skin |
| C439 | Malignant melanoma of skin, unspecified |
| C474 | Malignant neoplasm of peripheral nerves of abdomen |
| C494 | Malignant neoplasm of connective and soft tissue of abdomen |
| C49A0 | Gastrointestinal stromal tumor, unspecified site |
| C49A1 | Gastrointestinal stromal tumor of esophagus |
| C49A2 | Gastrointestinal stromal tumor of stomach |
| C49A3 | Gastrointestinal stromal tumor of small intestine |
| C49A4 | Gastrointestinal stromal tumor of large intestine |
| C49A5 | Gastrointestinal stromal tumor of rectum |
| C49A9 | Gastrointestinal stromal tumor of other sites |
| C50011 | Malignant neoplasm of nipple and areola, right female breast |
| C50012 | Malignant neoplasm of nipple and areola, left female breast |
| C50019 | Malignant neoplasm of nipple and areola, unspecified female breast |
| C50021 | Malignant neoplasm of nipple and areola, right male breast |
| C50022 | Malignant neoplasm of nipple and areola, left male breast |
| C50029 | Malignant neoplasm of nipple and areola, unspecified male breast |
| C50111 | Malignant neoplasm of central portion of right female breast |
| C50112 | Malignant neoplasm of central portion of left female breast |
| C50119 | Malignant neoplasm of central portion of unspecified female breast |
| C50121 | Malignant neoplasm of central portion of right male breast |
| C50122 | Malignant neoplasm of central portion of left male breast |
| C50129 | Malignant neoplasm of central portion of unspecified male breast |
| C50211 | Malignant neoplasm of upper-inner quadrant of right female breast |
| C50212 | Malignant neoplasm of upper-inner quadrant of left female breast |
| C50219 | Malignant neoplasm of upper-inner quadrant of unspecified female breast |
| C50221 | Malignant neoplasm of upper-inner quadrant of right male breast |
| C50222 | Malignant neoplasm of upper-inner quadrant of left male breast |
| C50229 | Malignant neoplasm of upper-inner quadrant of unspecified male breast |
| C50311 | Malignant neoplasm of lower-inner quadrant of right female breast |
| C50312 | Malignant neoplasm of lower-inner quadrant of left female breast |
| C50319 | Malignant neoplasm of lower-inner quadrant of unspecified female breast |
| C50321 | Malignant neoplasm of lower-inner quadrant of right male breast |
| C50322 | Malignant neoplasm of lower-inner quadrant of left male breast |
| C50329 | Malignant neoplasm of lower-inner quadrant of unspecified male breast |
| C50411 | Malignant neoplasm of upper-outer quadrant of right female breast |
| C50412 | Malignant neoplasm of upper-outer quadrant of left female breast |
| C50419 | Malignant neoplasm of upper-outer quadrant of unspecified female breast |
| C50421 | Malignant neoplasm of upper-outer quadrant of right male breast |
| C50422 | Malignant neoplasm of upper-outer quadrant of left male breast |
| C50429 | Malignant neoplasm of upper-outer quadrant of unspecified male breast |
| C50511 | Malignant neoplasm of lower-outer quadrant of right female breast |
| C50512 | Malignant neoplasm of lower-outer quadrant of left female breast |
| C50519 | Malignant neoplasm of lower-outer quadrant of unspecified female breast |
| C50521 | Malignant neoplasm of lower-outer quadrant of right male breast |
| C50522 | Malignant neoplasm of lower-outer quadrant of left male breast |
| C50529 | Malignant neoplasm of lower-outer quadrant of unspecified male breast |
| C50611 | Malignant neoplasm of axillary tail of right female breast |
| C50612 | Malignant neoplasm of axillary tail of left female breast |
| C50619 | Malignant neoplasm of axillary tail of unspecified female breast |
| C50621 | Malignant neoplasm of axillary tail of right male breast |
| C50622 | Malignant neoplasm of axillary tail of left male breast |
| C50629 | Malignant neoplasm of axillary tail of unspecified male breast |
| C50811 | Malignant neoplasm of overlapping sites of right female breast |
| C50812 | Malignant neoplasm of overlapping sites of left female breast |
| C50819 | Malignant neoplasm of overlapping sites of unspecified female breast |
| C50821 | Malignant neoplasm of overlapping sites of right male breast |
| C50822 | Malignant neoplasm of overlapping sites of left male breast |
| C50829 | Malignant neoplasm of overlapping sites of unspecified male breast |
| C50911 | Malignant neoplasm of unspecified site of right female breast |
| C50912 | Malignant neoplasm of unspecified site of left female breast |
| C50919 | Malignant neoplasm of unspecified site of unspecified female breast |
| C50921 | Malignant neoplasm of unspecified site of right male breast |
| C50922 | Malignant neoplasm of unspecified site of left male breast |
| C50929 | Malignant neoplasm of unspecified site of unspecified male breast |
| C50A0 | Malignant inflammatory neoplasm of unspecified breast |
| C50A1 | Malignant inflammatory neoplasm of right breast |
| C50A2 | Malignant inflammatory neoplasm of left breast |
| C540 | Malignant neoplasm of isthmus uteri |
| C541 | Malignant neoplasm of endometrium |
| C542 | Malignant neoplasm of myometrium |
| C543 | Malignant neoplasm of fundus uteri |
| C548 | Malignant neoplasm of overlapping sites of corpus uteri |
| C549 | Malignant neoplasm of corpus uteri, unspecified |
| C55 | Malignant neoplasm of uterus, part unspecified |
| C600 | Malignant neoplasm of prepuce |
| C601 | Malignant neoplasm of glans penis |
| C602 | Malignant neoplasm of body of penis |
| C608 | Malignant neoplasm of overlapping sites of penis |
| C609 | Malignant neoplasm of penis, unspecified |
| C61 | Malignant neoplasm of prostate |
| C6200 | Malignant neoplasm of unspecified undescended testis |
| C6201 | Malignant neoplasm of undescended right testis |
| C6202 | Malignant neoplasm of undescended left testis |
| C6210 | Malignant neoplasm of unspecified descended testis |
| C6211 | Malignant neoplasm of descended right testis |
| C6212 | Malignant neoplasm of descended left testis |
| C6290 | Malignant neoplasm of unspecified testis, unspecified whether descended or undescended |
| C6291 | Malignant neoplasm of right testis, unspecified whether descended or undescended |
| C6292 | Malignant neoplasm of left testis, unspecified whether descended or undescended |
| C6300 | Malignant neoplasm of unspecified epididymis |
| C6301 | Malignant neoplasm of right epididymis |
| C6302 | Malignant neoplasm of left epididymis |
| C6310 | Malignant neoplasm of unspecified spermatic cord |
| C6311 | Malignant neoplasm of right spermatic cord |
| C6312 | Malignant neoplasm of left spermatic cord |
| C632 | Malignant neoplasm of scrotum |
| C637 | Malignant neoplasm of other specified male genital organs |
| C638 | Malignant neoplasm of overlapping sites of male genital organs |
| C639 | Malignant neoplasm of male genital organ, unspecified |
| C6900 | Malignant neoplasm of unspecified conjunctiva |
| C6901 | Malignant neoplasm of right conjunctiva |
| C6902 | Malignant neoplasm of left conjunctiva |
| C6910 | Malignant neoplasm of unspecified cornea |
| C6911 | Malignant neoplasm of right cornea |
| C6912 | Malignant neoplasm of left cornea |
| C6920 | Malignant neoplasm of unspecified retina |
| C6921 | Malignant neoplasm of right retina |
| C6922 | Malignant neoplasm of left retina |
| C6930 | Malignant neoplasm of unspecified choroid |
| C6931 | Malignant neoplasm of right choroid |
| C6932 | Malignant neoplasm of left choroid |
| C6940 | Malignant neoplasm of unspecified ciliary body |
| C6941 | Malignant neoplasm of right ciliary body |
| C6942 | Malignant neoplasm of left ciliary body |
| C6950 | Malignant neoplasm of unspecified lacrimal gland and duct |
| C6951 | Malignant neoplasm of right lacrimal gland and duct |
| C6952 | Malignant neoplasm of left lacrimal gland and duct |
| C6960 | Malignant neoplasm of unspecified orbit |
| C6961 | Malignant neoplasm of right orbit |
| C6962 | Malignant neoplasm of left orbit |
| C6980 | Malignant neoplasm of overlapping sites of unspecified eye and adnexa |
| C6981 | Malignant neoplasm of overlapping sites of right eye and adnexa |
| C6982 | Malignant neoplasm of overlapping sites of left eye and adnexa |
| C6990 | Malignant neoplasm of unspecified site of unspecified eye |
| C6991 | Malignant neoplasm of unspecified site of right eye |
| C6992 | Malignant neoplasm of unspecified site of left eye |
| C73 | Malignant neoplasm of thyroid gland |
| C750 | Malignant neoplasm of parathyroid gland |
| C754 | Malignant neoplasm of carotid body |
| C755 | Malignant neoplasm of aortic body and other paraganglia |
| C758 | Malignant neoplasm with pluriglandular involvement, unspecified |
| C759 | Malignant neoplasm of endocrine gland, unspecified |
| C760 | Malignant neoplasm of head, face and neck |
| C761 | Malignant neoplasm of thorax |
| C762 | Malignant neoplasm of abdomen |
| C763 | Malignant neoplasm of pelvis |
| C7640 | Malignant neoplasm of unspecified upper limb |
| C7641 | Malignant neoplasm of right upper limb |
| C7642 | Malignant neoplasm of left upper limb |
| C7650 | Malignant neoplasm of unspecified lower limb |
| C7651 | Malignant neoplasm of right lower limb |
| C7652 | Malignant neoplasm of left lower limb |
| C768 | Malignant neoplasm of other specified ill-defined sites |
| C801 | Malignant (primary) neoplasm, unspecified |
| C802 | Malignant neoplasm associated with transplanted organ |
| D030 | Melanoma in situ of lip |
| D0310 | Melanoma in situ of unspecified eyelid, including canthus |
| D03111 | Melanoma in situ of right upper eyelid, including canthus |
| D03112 | Melanoma in situ of right lower eyelid, including canthus |
| D03121 | Melanoma in situ of left upper eyelid, including canthus |
| D03122 | Melanoma in situ of left lower eyelid, including canthus |
| D0320 | Melanoma in situ of unspecified ear and external auricular canal |
| D0321 | Melanoma in situ of right ear and external auricular canal |
| D0322 | Melanoma in situ of left ear and external auricular canal |
| D0330 | Melanoma in situ of unspecified part of face |
| D0339 | Melanoma in situ of other parts of face |
| D034 | Melanoma in situ of scalp and neck |
| D0351 | Melanoma in situ of anal skin |
| D0352 | Melanoma in situ of breast (skin) (soft tissue) |
| D0359 | Melanoma in situ of other part of trunk |
| D0360 | Melanoma in situ of unspecified upper limb, including shoulder |
| D0361 | Melanoma in situ of right upper limb, including shoulder |
| D0362 | Melanoma in situ of left upper limb, including shoulder |
| D0370 | Melanoma in situ of unspecified lower limb, including hip |
| D0371 | Melanoma in situ of right lower limb, including hip |
| D0372 | Melanoma in situ of left lower limb, including hip |
| D038 | Melanoma in situ of other sites |
| D039 | Melanoma in situ, unspecified |
| D1802 | Hemangioma of intracranial structures |
| D320 | Benign neoplasm of cerebral meninges |
| D321 | Benign neoplasm of spinal meninges |
| D329 | Benign neoplasm of meninges, unspecified |
| D330 | Benign neoplasm of brain, supratentorial |
| D331 | Benign neoplasm of brain, infratentorial |
| D332 | Benign neoplasm of brain, unspecified |
| D333 | Benign neoplasm of cranial nerves |
| D334 | Benign neoplasm of spinal cord |
| D337 | Benign neoplasm of other specified parts of central nervous system |
| D339 | Benign neoplasm of central nervous system, unspecified |
| D352 | Benign neoplasm of pituitary gland |
| D353 | Benign neoplasm of craniopharyngeal duct |
| D354 | Benign neoplasm of pineal gland |
| D420 | Neoplasm of uncertain behavior of cerebral meninges |
| D421 | Neoplasm of uncertain behavior of spinal meninges |
| D429 | Neoplasm of uncertain behavior of meninges, unspecified |
| D430 | Neoplasm of uncertain behavior of brain, supratentorial |
| D431 | Neoplasm of uncertain behavior of brain, infratentorial |
| D432 | Neoplasm of uncertain behavior of brain, unspecified |
| D433 | Neoplasm of uncertain behavior of cranial nerves |
| D434 | Neoplasm of uncertain behavior of spinal cord |
| D438 | Neoplasm of uncertain behavior of other specified parts of central nervous system |
| D439 | Neoplasm of uncertain behavior of central nervous system, unspecified |
| D443 | Neoplasm of uncertain behavior of pituitary gland |
| D444 | Neoplasm of uncertain behavior of craniopharyngeal duct |
| D445 | Neoplasm of uncertain behavior of pineal gland |
| D446 | Neoplasm of uncertain behavior of carotid body |
| D447 | Neoplasm of uncertain behavior of aortic body and other paraganglia |
| D45 | Polycythemia vera |
| D473 | Essential (hemorrhagic) thrombocythemia |
| D496 | Neoplasm of unspecified behavior of brain |
| Q8500 | Neurofibromatosis, unspecified |
| Q8501 | Neurofibromatosis, type 1 |
| Q8502 | Neurofibromatosis, type 2 |
| Q8503 | Schwannomatosis |
| Q8509 | Other neurofibromatosis |
| Q851 | Tuberous sclerosis |
| Q8581 | PTEN hamartoma tumor syndrome |
| Q8582 | Other Cowden syndrome |
| Q8583 | Von Hippel-Lindau syndrome |
| Q8589 | Other phakomatoses, not elsewhere classified |
| Q859 | Phakomatosis, 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 |
|---|---|
| 12 | 223 |
| 10 | 9 |
| 48 | 2 |
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 23?
234 ICD-10-CM codes map to HCC 23 in the CMS PY2027 initial mapping, for example C430 Malignant melanoma of lip; C4310 Malignant melanoma of unspecified eyelid, including canthus; C43111 Malignant melanoma of right upper eyelid, including canthus; C43112 Malignant melanoma of right lower eyelid, including canthus. 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 23 add to a risk score?
The V28 relative factor for HCC 23 is 0.186 for a community, non-dual, aged beneficiary, 0.196 for full-benefit dual aged, 0.233 for non-dual disabled and 0.197 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 23 count together with related categories?
No. Within a hierarchy only the most severe category is paid. HCC 23 is dropped when HCC 17 (Cancer Metastatic to Lung, Liver, Brain, and Other Organs; Acute Myeloid Leukemia Except Promyelocytic) or HCC 18 (Cancer Metastatic to Bone, Other and Unspecified Metastatic Cancer; Acute Leukemia Except Myeloid) or HCC 19 (Myelodysplastic Syndromes, Multiple Myeloma, and Other Cancers) or HCC 20 (Lung and Other Severe Cancers) or HCC 21 (Lymphoma and Other Cancers) or HCC 22 (Bladder, Colorectal, and Other Cancers) is also present.
What has to be documented for HCC 23 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.