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_HCC37 | 0.166 |
| Community, non-dual, disabled | CND_HCC37 | 0.191 |
| Community, full-benefit dual, aged | CFA_HCC37 | 0.186 |
| Community, full-benefit dual, disabled | CFD_HCC37 | 0.235 |
| Community, partial-benefit dual, aged | CPA_HCC37 | 0.166 |
| Community, partial-benefit dual, disabled | CPD_HCC37 | 0.210 |
| Long-term institutional | INS_HCC37 | 0.280 |
Hierarchy
Hierarchical condition categories pay only the most severe manifestation of a disease. When HCC 35 (Pancreas Transplant Status) or HCC 36 (Diabetes with Severe Acute Complications) is also documented for the same beneficiary, HCC 37 is dropped from the score. When HCC 37 is present it drops HCC 38 (Diabetes with Glycemic, Unspecified, or No 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 37
308 codes map to this category in the PY2027 initial mapping, concentrated in the E08 (77), E10 (77), E11 (77), E13 (77) 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 |
|---|---|
| E0821 | Diabetes mellitus due to underlying condition with diabetic nephropathy |
| E0822 | Diabetes mellitus due to underlying condition with diabetic chronic kidney disease |
| E0829 | Diabetes mellitus due to underlying condition with other diabetic kidney complication |
| E08311 | Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema |
| E08319 | Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema |
| E083211 | Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye |
| E083212 | Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye |
| E083213 | Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral |
| E083219 | Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye |
| E083291 | Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye |
| E083292 | Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye |
| E083293 | Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral |
| E083299 | Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye |
| E083311 | Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye |
| E083312 | Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye |
| E083313 | Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral |
| E083319 | Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye |
| E083391 | Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye |
| E083392 | Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye |
| E083393 | Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral |
| E083399 | Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye |
| E083411 | Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye |
| E083412 | Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye |
| E083413 | Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral |
| E083419 | Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye |
| E083491 | Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye |
| E083492 | Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye |
| E083493 | Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral |
| E083499 | Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye |
| E083511 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye |
| E083512 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye |
| E083513 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral |
| E083519 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, unspecified eye |
| E083521 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye |
| E083522 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye |
| E083523 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral |
| E083529 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye |
| E083531 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye |
| E083532 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye |
| E083533 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral |
| E083539 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye |
| E083541 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye |
| E083542 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye |
| E083543 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral |
| E083549 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye |
| E083551 | Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye |
| E083552 | Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye |
| E083553 | Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral |
| E083559 | Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, unspecified eye |
| E083591 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right eye |
| E083592 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, left eye |
| E083593 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, bilateral |
| E083599 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, unspecified eye |
| E0836 | Diabetes mellitus due to underlying condition with diabetic cataract |
| E0837X1 | Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, right eye |
| E0837X2 | Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, left eye |
| E0837X3 | Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, bilateral |
| E0837X9 | Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, unspecified eye |
| E0839 | Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication |
| E0840 | Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified |
| E0841 | Diabetes mellitus due to underlying condition with diabetic mononeuropathy |
| E0842 | Diabetes mellitus due to underlying condition with diabetic polyneuropathy |
| E0843 | Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy |
| E0844 | Diabetes mellitus due to underlying condition with diabetic amyotrophy |
| E0849 | Diabetes mellitus due to underlying condition with other diabetic neurological complication |
| E0851 | Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene |
| E0852 | Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene |
| E0859 | Diabetes mellitus due to underlying condition with other circulatory complications |
| E08610 | Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy |
| E08618 | Diabetes mellitus due to underlying condition with other diabetic arthropathy |
| E08620 | Diabetes mellitus due to underlying condition with diabetic dermatitis |
| E08621 | Diabetes mellitus due to underlying condition with foot ulcer |
| E08622 | Diabetes mellitus due to underlying condition with other skin ulcer |
| E08628 | Diabetes mellitus due to underlying condition with other skin complications |
| E08630 | Diabetes mellitus due to underlying condition with periodontal disease |
| E08638 | Diabetes mellitus due to underlying condition with other oral complications |
| E0869 | Diabetes mellitus due to underlying condition with other specified complication |
| E1021 | Type 1 diabetes mellitus with diabetic nephropathy |
| E1022 | Type 1 diabetes mellitus with diabetic chronic kidney disease |
| E1029 | Type 1 diabetes mellitus with other diabetic kidney complication |
| E10311 | Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema |
| E10319 | Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema |
| E103211 | Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye |
| E103212 | Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye |
| E103213 | Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral |
| E103219 | Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye |
| E103291 | Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye |
| E103292 | Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye |
| E103293 | Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral |
| E103299 | Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye |
| E103311 | Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye |
| E103312 | Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye |
| E103313 | Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral |
| E103319 | Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye |
| E103391 | Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye |
| E103392 | Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye |
| E103393 | Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral |
| E103399 | Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye |
| E103411 | Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye |
| E103412 | Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye |
| E103413 | Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral |
| E103419 | Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye |
| E103491 | Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye |
| E103492 | Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye |
| E103493 | Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral |
| E103499 | Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye |
| E103511 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye |
| E103512 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye |
| E103513 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral |
| E103519 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye |
| E103521 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye |
| E103522 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye |
| E103523 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral |
| E103529 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye |
| E103531 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye |
| E103532 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye |
| E103533 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral |
| E103539 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye |
| E103541 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye |
| E103542 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye |
| E103543 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral |
| E103549 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye |
| E103551 | Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye |
| E103552 | Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye |
| E103553 | Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral |
| E103559 | Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye |
| E103591 | Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye |
| E103592 | Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye |
| E103593 | Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral |
| E103599 | Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye |
| E1036 | Type 1 diabetes mellitus with diabetic cataract |
| E1037X1 | Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye |
| E1037X2 | Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye |
| E1037X3 | Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral |
| E1037X9 | Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye |
| E1039 | Type 1 diabetes mellitus with other diabetic ophthalmic complication |
| E1040 | Type 1 diabetes mellitus with diabetic neuropathy, unspecified |
| E1041 | Type 1 diabetes mellitus with diabetic mononeuropathy |
| E1042 | Type 1 diabetes mellitus with diabetic polyneuropathy |
| E1043 | Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy |
| E1044 | Type 1 diabetes mellitus with diabetic amyotrophy |
| E1049 | Type 1 diabetes mellitus with other diabetic neurological complication |
| E1051 | Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene |
| E1052 | Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene |
| E1059 | Type 1 diabetes mellitus with other circulatory complications |
| E10610 | Type 1 diabetes mellitus with diabetic neuropathic arthropathy |
| E10618 | Type 1 diabetes mellitus with other diabetic arthropathy |
| E10620 | Type 1 diabetes mellitus with diabetic dermatitis |
| E10621 | Type 1 diabetes mellitus with foot ulcer |
| E10622 | Type 1 diabetes mellitus with other skin ulcer |
| E10628 | Type 1 diabetes mellitus with other skin complications |
| E10630 | Type 1 diabetes mellitus with periodontal disease |
| E10638 | Type 1 diabetes mellitus with other oral complications |
| E1069 | Type 1 diabetes mellitus with other specified complication |
| E1121 | Type 2 diabetes mellitus with diabetic nephropathy |
| E1122 | Type 2 diabetes mellitus with diabetic chronic kidney disease |
| E1129 | Type 2 diabetes mellitus with other diabetic kidney complication |
| E11311 | Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema |
| E11319 | Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema |
| E113211 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye |
| E113212 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye |
| E113213 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral |
| E113219 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye |
| E113291 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye |
| E113292 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye |
| E113293 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral |
| E113299 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye |
| E113311 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye |
| E113312 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye |
| E113313 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral |
| E113319 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye |
| E113391 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye |
| E113392 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye |
| E113393 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral |
| E113399 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye |
| E113411 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye |
| E113412 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye |
| E113413 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral |
| E113419 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye |
| E113491 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye |
| E113492 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye |
| E113493 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral |
| E113499 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye |
| E113511 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye |
| E113512 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye |
| E113513 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral |
| E113519 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye |
| E113521 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye |
| E113522 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye |
| E113523 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral |
| E113529 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye |
| E113531 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye |
| E113532 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye |
| E113533 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral |
| E113539 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye |
| E113541 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye |
| E113542 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye |
| E113543 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral |
| E113549 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye |
| E113551 | Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye |
| E113552 | Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye |
| E113553 | Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral |
| E113559 | Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye |
| E113591 | Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye |
| E113592 | Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye |
| E113593 | Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral |
| E113599 | Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye |
| E1136 | Type 2 diabetes mellitus with diabetic cataract |
| E1137X1 | Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye |
| E1137X2 | Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye |
| E1137X3 | Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral |
| E1137X9 | Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye |
| E1139 | Type 2 diabetes mellitus with other diabetic ophthalmic complication |
| E1140 | Type 2 diabetes mellitus with diabetic neuropathy, unspecified |
| E1141 | Type 2 diabetes mellitus with diabetic mononeuropathy |
| E1142 | Type 2 diabetes mellitus with diabetic polyneuropathy |
| E1143 | Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy |
| E1144 | Type 2 diabetes mellitus with diabetic amyotrophy |
| E1149 | Type 2 diabetes mellitus with other diabetic neurological complication |
| E1151 | Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene |
| E1152 | Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene |
| E1159 | Type 2 diabetes mellitus with other circulatory complications |
| E11610 | Type 2 diabetes mellitus with diabetic neuropathic arthropathy |
| E11618 | Type 2 diabetes mellitus with other diabetic arthropathy |
| E11620 | Type 2 diabetes mellitus with diabetic dermatitis |
| E11621 | Type 2 diabetes mellitus with foot ulcer |
| E11622 | Type 2 diabetes mellitus with other skin ulcer |
| E11628 | Type 2 diabetes mellitus with other skin complications |
| E11630 | Type 2 diabetes mellitus with periodontal disease |
| E11638 | Type 2 diabetes mellitus with other oral complications |
| E1169 | Type 2 diabetes mellitus with other specified complication |
| E1321 | Other specified diabetes mellitus with diabetic nephropathy |
| E1322 | Other specified diabetes mellitus with diabetic chronic kidney disease |
| E1329 | Other specified diabetes mellitus with other diabetic kidney complication |
| E13311 | Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema |
| E13319 | Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema |
| E133211 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye |
| E133212 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye |
| E133213 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral |
| E133219 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye |
| E133291 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye |
| E133292 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye |
| E133293 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral |
| E133299 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye |
| E133311 | Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye |
| E133312 | Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye |
| E133313 | Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral |
| E133319 | Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye |
| E133391 | Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye |
| E133392 | Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye |
| E133393 | Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral |
| E133399 | Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye |
| E133411 | Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye |
| E133412 | Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye |
| E133413 | Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral |
| E133419 | Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye |
| E133491 | Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye |
| E133492 | Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye |
| E133493 | Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral |
| E133499 | Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye |
| E133511 | Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye |
| E133512 | Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye |
| E133513 | Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral |
| E133519 | Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye |
| E133521 | Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye |
| E133522 | Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye |
| E133523 | Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral |
| E133529 | Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye |
| E133531 | Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye |
| E133532 | Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye |
| E133533 | Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral |
| E133539 | Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye |
| E133541 | Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye |
| E133542 | Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye |
| E133543 | Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral |
| E133549 | Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye |
| E133551 | Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye |
| E133552 | Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye |
| E133553 | Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral |
| E133559 | Other specified diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye |
| E133591 | Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye |
| E133592 | Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye |
| E133593 | Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral |
| E133599 | Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye |
| E1336 | Other specified diabetes mellitus with diabetic cataract |
| E1337X1 | Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, right eye |
| E1337X2 | Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, left eye |
| E1337X3 | Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral |
| E1337X9 | Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye |
| E1339 | Other specified diabetes mellitus with other diabetic ophthalmic complication |
| E1340 | Other specified diabetes mellitus with diabetic neuropathy, unspecified |
| E1341 | Other specified diabetes mellitus with diabetic mononeuropathy |
| E1342 | Other specified diabetes mellitus with diabetic polyneuropathy |
| E1343 | Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy |
| E1344 | Other specified diabetes mellitus with diabetic amyotrophy |
| E1349 | Other specified diabetes mellitus with other diabetic neurological complication |
| E1351 | Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene |
| E1352 | Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene |
| E1359 | Other specified diabetes mellitus with other circulatory complications |
| E13610 | Other specified diabetes mellitus with diabetic neuropathic arthropathy |
| E13618 | Other specified diabetes mellitus with other diabetic arthropathy |
| E13620 | Other specified diabetes mellitus with diabetic dermatitis |
| E13621 | Other specified diabetes mellitus with foot ulcer |
| E13622 | Other specified diabetes mellitus with other skin ulcer |
| E13628 | Other specified diabetes mellitus with other skin complications |
| E13630 | Other specified diabetes mellitus with periodontal disease |
| E13638 | Other specified diabetes mellitus with other oral complications |
| E1369 | Other specified diabetes mellitus with other specified complication |
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 |
|---|---|
| 18 | 308 |
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 37?
308 ICD-10-CM codes map to HCC 37 in the CMS PY2027 initial mapping, for example E0821 Diabetes mellitus due to underlying condition with diabetic nephropathy; E0822 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease; E0829 Diabetes mellitus due to underlying condition with other diabetic kidney complication; E08311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema. 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 37 add to a risk score?
The V28 relative factor for HCC 37 is 0.166 for a community, non-dual, aged beneficiary, 0.186 for full-benefit dual aged, 0.191 for non-dual disabled and 0.280 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 37 count together with related categories?
No. Within a hierarchy only the most severe category is paid. HCC 37 is dropped when HCC 35 (Pancreas Transplant Status) or HCC 36 (Diabetes with Severe Acute Complications) is also present, and it drops HCC 38 when it is present.
What has to be documented for HCC 37 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.