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_HCC401 | 0.522 |
| Community, non-dual, disabled | CND_HCC401 | 0.605 |
| Community, full-benefit dual, aged | CFA_HCC401 | 0.622 |
| Community, full-benefit dual, disabled | CFD_HCC401 | 0.559 |
| Community, partial-benefit dual, aged | CPA_HCC401 | 0.538 |
| Community, partial-benefit dual, disabled | CPD_HCC401 | 0.412 |
| Long-term institutional | INS_HCC401 | 0.231 |
Hierarchy
HCC 401 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 401
339 codes map to this category in the PY2027 initial mapping, concentrated in the S12 (140), S32 (98), S22 (90), M48 (9), M80 (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 |
|---|---|
| M4850XA | Collapsed vertebra, not elsewhere classified, site unspecified, initial encounter for fracture |
| M4851XA | Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, initial encounter for fracture |
| M4852XA | Collapsed vertebra, not elsewhere classified, cervical region, initial encounter for fracture |
| M4853XA | Collapsed vertebra, not elsewhere classified, cervicothoracic region, initial encounter for fracture |
| M4854XA | Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture |
| M4855XA | Collapsed vertebra, not elsewhere classified, thoracolumbar region, initial encounter for fracture |
| M4856XA | Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture |
| M4857XA | Collapsed vertebra, not elsewhere classified, lumbosacral region, initial encounter for fracture |
| M4858XA | Collapsed vertebra, not elsewhere classified, sacral and sacrococcygeal region, initial encounter for fracture |
| M8008XA | Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture |
| M8088XA | Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture |
| S12000A | Unspecified displaced fracture of first cervical vertebra, initial encounter for closed fracture |
| S12000B | Unspecified displaced fracture of first cervical vertebra, initial encounter for open fracture |
| S12001A | Unspecified nondisplaced fracture of first cervical vertebra, initial encounter for closed fracture |
| S12001B | Unspecified nondisplaced fracture of first cervical vertebra, initial encounter for open fracture |
| S1201XA | Stable burst fracture of first cervical vertebra, initial encounter for closed fracture |
| S1201XB | Stable burst fracture of first cervical vertebra, initial encounter for open fracture |
| S1202XA | Unstable burst fracture of first cervical vertebra, initial encounter for closed fracture |
| S1202XB | Unstable burst fracture of first cervical vertebra, initial encounter for open fracture |
| S12030A | Displaced posterior arch fracture of first cervical vertebra, initial encounter for closed fracture |
| S12030B | Displaced posterior arch fracture of first cervical vertebra, initial encounter for open fracture |
| S12031A | Nondisplaced posterior arch fracture of first cervical vertebra, initial encounter for closed fracture |
| S12031B | Nondisplaced posterior arch fracture of first cervical vertebra, initial encounter for open fracture |
| S12040A | Displaced lateral mass fracture of first cervical vertebra, initial encounter for closed fracture |
| S12040B | Displaced lateral mass fracture of first cervical vertebra, initial encounter for open fracture |
| S12041A | Nondisplaced lateral mass fracture of first cervical vertebra, initial encounter for closed fracture |
| S12041B | Nondisplaced lateral mass fracture of first cervical vertebra, initial encounter for open fracture |
| S12090A | Other displaced fracture of first cervical vertebra, initial encounter for closed fracture |
| S12090B | Other displaced fracture of first cervical vertebra, initial encounter for open fracture |
| S12091A | Other nondisplaced fracture of first cervical vertebra, initial encounter for closed fracture |
| S12091B | Other nondisplaced fracture of first cervical vertebra, initial encounter for open fracture |
| S12100A | Unspecified displaced fracture of second cervical vertebra, initial encounter for closed fracture |
| S12100B | Unspecified displaced fracture of second cervical vertebra, initial encounter for open fracture |
| S12101A | Unspecified nondisplaced fracture of second cervical vertebra, initial encounter for closed fracture |
| S12101B | Unspecified nondisplaced fracture of second cervical vertebra, initial encounter for open fracture |
| S12110A | Anterior displaced Type II dens fracture, initial encounter for closed fracture |
| S12110B | Anterior displaced Type II dens fracture, initial encounter for open fracture |
| S12111A | Posterior displaced Type II dens fracture, initial encounter for closed fracture |
| S12111B | Posterior displaced Type II dens fracture, initial encounter for open fracture |
| S12112A | Nondisplaced Type II dens fracture, initial encounter for closed fracture |
| S12112B | Nondisplaced Type II dens fracture, initial encounter for open fracture |
| S12120A | Other displaced dens fracture, initial encounter for closed fracture |
| S12120B | Other displaced dens fracture, initial encounter for open fracture |
| S12121A | Other nondisplaced dens fracture, initial encounter for closed fracture |
| S12121B | Other nondisplaced dens fracture, initial encounter for open fracture |
| S12130A | Unspecified traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for closed fracture |
| S12130B | Unspecified traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for open fracture |
| S12131A | Unspecified traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial encounter for closed fracture |
| S12131B | Unspecified traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial encounter for open fracture |
| S1214XA | Type III traumatic spondylolisthesis of second cervical vertebra, initial encounter for closed fracture |
| S1214XB | Type III traumatic spondylolisthesis of second cervical vertebra, initial encounter for open fracture |
| S12150A | Other traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for closed fracture |
| S12150B | Other traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for open fracture |
| S12151A | Other traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial encounter for closed fracture |
| S12151B | Other traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial encounter for open fracture |
| S12190A | Other displaced fracture of second cervical vertebra, initial encounter for closed fracture |
| S12190B | Other displaced fracture of second cervical vertebra, initial encounter for open fracture |
| S12191A | Other nondisplaced fracture of second cervical vertebra, initial encounter for closed fracture |
| S12191B | Other nondisplaced fracture of second cervical vertebra, initial encounter for open fracture |
| S12200A | Unspecified displaced fracture of third cervical vertebra, initial encounter for closed fracture |
| S12200B | Unspecified displaced fracture of third cervical vertebra, initial encounter for open fracture |
| S12201A | Unspecified nondisplaced fracture of third cervical vertebra, initial encounter for closed fracture |
| S12201B | Unspecified nondisplaced fracture of third cervical vertebra, initial encounter for open fracture |
| S12230A | Unspecified traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for closed fracture |
| S12230B | Unspecified traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for open fracture |
| S12231A | Unspecified traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial encounter for closed fracture |
| S12231B | Unspecified traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial encounter for open fracture |
| S1224XA | Type III traumatic spondylolisthesis of third cervical vertebra, initial encounter for closed fracture |
| S1224XB | Type III traumatic spondylolisthesis of third cervical vertebra, initial encounter for open fracture |
| S12250A | Other traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for closed fracture |
| S12250B | Other traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for open fracture |
| S12251A | Other traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial encounter for closed fracture |
| S12251B | Other traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial encounter for open fracture |
| S12290A | Other displaced fracture of third cervical vertebra, initial encounter for closed fracture |
| S12290B | Other displaced fracture of third cervical vertebra, initial encounter for open fracture |
| S12291A | Other nondisplaced fracture of third cervical vertebra, initial encounter for closed fracture |
| S12291B | Other nondisplaced fracture of third cervical vertebra, initial encounter for open fracture |
| S12300A | Unspecified displaced fracture of fourth cervical vertebra, initial encounter for closed fracture |
| S12300B | Unspecified displaced fracture of fourth cervical vertebra, initial encounter for open fracture |
| S12301A | Unspecified nondisplaced fracture of fourth cervical vertebra, initial encounter for closed fracture |
| S12301B | Unspecified nondisplaced fracture of fourth cervical vertebra, initial encounter for open fracture |
| S12330A | Unspecified traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for closed fracture |
| S12330B | Unspecified traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for open fracture |
| S12331A | Unspecified traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial encounter for closed fracture |
| S12331B | Unspecified traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial encounter for open fracture |
| S1234XA | Type III traumatic spondylolisthesis of fourth cervical vertebra, initial encounter for closed fracture |
| S1234XB | Type III traumatic spondylolisthesis of fourth cervical vertebra, initial encounter for open fracture |
| S12350A | Other traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for closed fracture |
| S12350B | Other traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for open fracture |
| S12351A | Other traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial encounter for closed fracture |
| S12351B | Other traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial encounter for open fracture |
| S12390A | Other displaced fracture of fourth cervical vertebra, initial encounter for closed fracture |
| S12390B | Other displaced fracture of fourth cervical vertebra, initial encounter for open fracture |
| S12391A | Other nondisplaced fracture of fourth cervical vertebra, initial encounter for closed fracture |
| S12391B | Other nondisplaced fracture of fourth cervical vertebra, initial encounter for open fracture |
| S12400A | Unspecified displaced fracture of fifth cervical vertebra, initial encounter for closed fracture |
| S12400B | Unspecified displaced fracture of fifth cervical vertebra, initial encounter for open fracture |
| S12401A | Unspecified nondisplaced fracture of fifth cervical vertebra, initial encounter for closed fracture |
| S12401B | Unspecified nondisplaced fracture of fifth cervical vertebra, initial encounter for open fracture |
| S12430A | Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture |
| S12430B | Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for open fracture |
| S12431A | Unspecified traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture |
| S12431B | Unspecified traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for open fracture |
| S1244XA | Type III traumatic spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture |
| S1244XB | Type III traumatic spondylolisthesis of fifth cervical vertebra, initial encounter for open fracture |
| S12450A | Other traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture |
| S12450B | Other traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for open fracture |
| S12451A | Other traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture |
| S12451B | Other traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for open fracture |
| S12490A | Other displaced fracture of fifth cervical vertebra, initial encounter for closed fracture |
| S12490B | Other displaced fracture of fifth cervical vertebra, initial encounter for open fracture |
| S12491A | Other nondisplaced fracture of fifth cervical vertebra, initial encounter for closed fracture |
| S12491B | Other nondisplaced fracture of fifth cervical vertebra, initial encounter for open fracture |
| S12500A | Unspecified displaced fracture of sixth cervical vertebra, initial encounter for closed fracture |
| S12500B | Unspecified displaced fracture of sixth cervical vertebra, initial encounter for open fracture |
| S12501A | Unspecified nondisplaced fracture of sixth cervical vertebra, initial encounter for closed fracture |
| S12501B | Unspecified nondisplaced fracture of sixth cervical vertebra, initial encounter for open fracture |
| S12530A | Unspecified traumatic displaced spondylolisthesis of sixth cervical vertebra, initial encounter for closed fracture |
| S12530B | Unspecified traumatic displaced spondylolisthesis of sixth cervical vertebra, initial encounter for open fracture |
| S12531A | Unspecified traumatic nondisplaced spondylolisthesis of sixth cervical vertebra, initial encounter for closed fracture |
| S12531B | Unspecified traumatic nondisplaced spondylolisthesis of sixth cervical vertebra, initial encounter for open fracture |
| S1254XA | Type III traumatic spondylolisthesis of sixth cervical vertebra, initial encounter for closed fracture |
| S1254XB | Type III traumatic spondylolisthesis of sixth cervical vertebra, initial encounter for open fracture |
| S12550A | Other traumatic displaced spondylolisthesis of sixth cervical vertebra, initial encounter for closed fracture |
| S12550B | Other traumatic displaced spondylolisthesis of sixth cervical vertebra, initial encounter for open fracture |
| S12551A | Other traumatic nondisplaced spondylolisthesis of sixth cervical vertebra, initial encounter for closed fracture |
| S12551B | Other traumatic nondisplaced spondylolisthesis of sixth cervical vertebra, initial encounter for open fracture |
| S12590A | Other displaced fracture of sixth cervical vertebra, initial encounter for closed fracture |
| S12590B | Other displaced fracture of sixth cervical vertebra, initial encounter for open fracture |
| S12591A | Other nondisplaced fracture of sixth cervical vertebra, initial encounter for closed fracture |
| S12591B | Other nondisplaced fracture of sixth cervical vertebra, initial encounter for open fracture |
| S12600A | Unspecified displaced fracture of seventh cervical vertebra, initial encounter for closed fracture |
| S12600B | Unspecified displaced fracture of seventh cervical vertebra, initial encounter for open fracture |
| S12601A | Unspecified nondisplaced fracture of seventh cervical vertebra, initial encounter for closed fracture |
| S12601B | Unspecified nondisplaced fracture of seventh cervical vertebra, initial encounter for open fracture |
| S12630A | Unspecified traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for closed fracture |
| S12630B | Unspecified traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for open fracture |
| S12631A | Unspecified traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial encounter for closed fracture |
| S12631B | Unspecified traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial encounter for open fracture |
| S1264XA | Type III traumatic spondylolisthesis of seventh cervical vertebra, initial encounter for closed fracture |
| S1264XB | Type III traumatic spondylolisthesis of seventh cervical vertebra, initial encounter for open fracture |
| S12650A | Other traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for closed fracture |
| S12650B | Other traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for open fracture |
| S12651A | Other traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial encounter for closed fracture |
| S12651B | Other traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial encounter for open fracture |
| S12690A | Other displaced fracture of seventh cervical vertebra, initial encounter for closed fracture |
| S12690B | Other displaced fracture of seventh cervical vertebra, initial encounter for open fracture |
| S12691A | Other nondisplaced fracture of seventh cervical vertebra, initial encounter for closed fracture |
| S12691B | Other nondisplaced fracture of seventh cervical vertebra, initial encounter for open fracture |
| S128XXA | Fracture of other parts of neck, initial encounter |
| S129XXA | Fracture of neck, unspecified, initial encounter |
| S22000A | Wedge compression fracture of unspecified thoracic vertebra, initial encounter for closed fracture |
| S22000B | Wedge compression fracture of unspecified thoracic vertebra, initial encounter for open fracture |
| S22001A | Stable burst fracture of unspecified thoracic vertebra, initial encounter for closed fracture |
| S22001B | Stable burst fracture of unspecified thoracic vertebra, initial encounter for open fracture |
| S22002A | Unstable burst fracture of unspecified thoracic vertebra, initial encounter for closed fracture |
| S22002B | Unstable burst fracture of unspecified thoracic vertebra, initial encounter for open fracture |
| S22008A | Other fracture of unspecified thoracic vertebra, initial encounter for closed fracture |
| S22008B | Other fracture of unspecified thoracic vertebra, initial encounter for open fracture |
| S22009A | Unspecified fracture of unspecified thoracic vertebra, initial encounter for closed fracture |
| S22009B | Unspecified fracture of unspecified thoracic vertebra, initial encounter for open fracture |
| S22010A | Wedge compression fracture of first thoracic vertebra, initial encounter for closed fracture |
| S22010B | Wedge compression fracture of first thoracic vertebra, initial encounter for open fracture |
| S22011A | Stable burst fracture of first thoracic vertebra, initial encounter for closed fracture |
| S22011B | Stable burst fracture of first thoracic vertebra, initial encounter for open fracture |
| S22012A | Unstable burst fracture of first thoracic vertebra, initial encounter for closed fracture |
| S22012B | Unstable burst fracture of first thoracic vertebra, initial encounter for open fracture |
| S22018A | Other fracture of first thoracic vertebra, initial encounter for closed fracture |
| S22018B | Other fracture of first thoracic vertebra, initial encounter for open fracture |
| S22019A | Unspecified fracture of first thoracic vertebra, initial encounter for closed fracture |
| S22019B | Unspecified fracture of first thoracic vertebra, initial encounter for open fracture |
| S22020A | Wedge compression fracture of second thoracic vertebra, initial encounter for closed fracture |
| S22020B | Wedge compression fracture of second thoracic vertebra, initial encounter for open fracture |
| S22021A | Stable burst fracture of second thoracic vertebra, initial encounter for closed fracture |
| S22021B | Stable burst fracture of second thoracic vertebra, initial encounter for open fracture |
| S22022A | Unstable burst fracture of second thoracic vertebra, initial encounter for closed fracture |
| S22022B | Unstable burst fracture of second thoracic vertebra, initial encounter for open fracture |
| S22028A | Other fracture of second thoracic vertebra, initial encounter for closed fracture |
| S22028B | Other fracture of second thoracic vertebra, initial encounter for open fracture |
| S22029A | Unspecified fracture of second thoracic vertebra, initial encounter for closed fracture |
| S22029B | Unspecified fracture of second thoracic vertebra, initial encounter for open fracture |
| S22030A | Wedge compression fracture of third thoracic vertebra, initial encounter for closed fracture |
| S22030B | Wedge compression fracture of third thoracic vertebra, initial encounter for open fracture |
| S22031A | Stable burst fracture of third thoracic vertebra, initial encounter for closed fracture |
| S22031B | Stable burst fracture of third thoracic vertebra, initial encounter for open fracture |
| S22032A | Unstable burst fracture of third thoracic vertebra, initial encounter for closed fracture |
| S22032B | Unstable burst fracture of third thoracic vertebra, initial encounter for open fracture |
| S22038A | Other fracture of third thoracic vertebra, initial encounter for closed fracture |
| S22038B | Other fracture of third thoracic vertebra, initial encounter for open fracture |
| S22039A | Unspecified fracture of third thoracic vertebra, initial encounter for closed fracture |
| S22039B | Unspecified fracture of third thoracic vertebra, initial encounter for open fracture |
| S22040A | Wedge compression fracture of fourth thoracic vertebra, initial encounter for closed fracture |
| S22040B | Wedge compression fracture of fourth thoracic vertebra, initial encounter for open fracture |
| S22041A | Stable burst fracture of fourth thoracic vertebra, initial encounter for closed fracture |
| S22041B | Stable burst fracture of fourth thoracic vertebra, initial encounter for open fracture |
| S22042A | Unstable burst fracture of fourth thoracic vertebra, initial encounter for closed fracture |
| S22042B | Unstable burst fracture of fourth thoracic vertebra, initial encounter for open fracture |
| S22048A | Other fracture of fourth thoracic vertebra, initial encounter for closed fracture |
| S22048B | Other fracture of fourth thoracic vertebra, initial encounter for open fracture |
| S22049A | Unspecified fracture of fourth thoracic vertebra, initial encounter for closed fracture |
| S22049B | Unspecified fracture of fourth thoracic vertebra, initial encounter for open fracture |
| S22050A | Wedge compression fracture of T5-T6 vertebra, initial encounter for closed fracture |
| S22050B | Wedge compression fracture of T5-T6 vertebra, initial encounter for open fracture |
| S22051A | Stable burst fracture of T5-T6 vertebra, initial encounter for closed fracture |
| S22051B | Stable burst fracture of T5-T6 vertebra, initial encounter for open fracture |
| S22052A | Unstable burst fracture of T5-T6 vertebra, initial encounter for closed fracture |
| S22052B | Unstable burst fracture of T5-T6 vertebra, initial encounter for open fracture |
| S22058A | Other fracture of T5-T6 vertebra, initial encounter for closed fracture |
| S22058B | Other fracture of T5-T6 vertebra, initial encounter for open fracture |
| S22059A | Unspecified fracture of T5-T6 vertebra, initial encounter for closed fracture |
| S22059B | Unspecified fracture of T5-T6 vertebra, initial encounter for open fracture |
| S22060A | Wedge compression fracture of T7-T8 vertebra, initial encounter for closed fracture |
| S22060B | Wedge compression fracture of T7-T8 vertebra, initial encounter for open fracture |
| S22061A | Stable burst fracture of T7-T8 vertebra, initial encounter for closed fracture |
| S22061B | Stable burst fracture of T7-T8 vertebra, initial encounter for open fracture |
| S22062A | Unstable burst fracture of T7-T8 vertebra, initial encounter for closed fracture |
| S22062B | Unstable burst fracture of T7-T8 vertebra, initial encounter for open fracture |
| S22068A | Other fracture of T7-T8 thoracic vertebra, initial encounter for closed fracture |
| S22068B | Other fracture of T7-T8 thoracic vertebra, initial encounter for open fracture |
| S22069A | Unspecified fracture of T7-T8 vertebra, initial encounter for closed fracture |
| S22069B | Unspecified fracture of T7-T8 vertebra, initial encounter for open fracture |
| S22070A | Wedge compression fracture of T9-T10 vertebra, initial encounter for closed fracture |
| S22070B | Wedge compression fracture of T9-T10 vertebra, initial encounter for open fracture |
| S22071A | Stable burst fracture of T9-T10 vertebra, initial encounter for closed fracture |
| S22071B | Stable burst fracture of T9-T10 vertebra, initial encounter for open fracture |
| S22072A | Unstable burst fracture of T9-T10 vertebra, initial encounter for closed fracture |
| S22072B | Unstable burst fracture of T9-T10 vertebra, initial encounter for open fracture |
| S22078A | Other fracture of T9-T10 vertebra, initial encounter for closed fracture |
| S22078B | Other fracture of T9-T10 vertebra, initial encounter for open fracture |
| S22079A | Unspecified fracture of T9-T10 vertebra, initial encounter for closed fracture |
| S22079B | Unspecified fracture of T9-T10 vertebra, initial encounter for open fracture |
| S22080A | Wedge compression fracture of T11-T12 vertebra, initial encounter for closed fracture |
| S22080B | Wedge compression fracture of T11-T12 vertebra, initial encounter for open fracture |
| S22081A | Stable burst fracture of T11-T12 vertebra, initial encounter for closed fracture |
| S22081B | Stable burst fracture of T11-T12 vertebra, initial encounter for open fracture |
| S22082A | Unstable burst fracture of T11-T12 vertebra, initial encounter for closed fracture |
| S22082B | Unstable burst fracture of T11-T12 vertebra, initial encounter for open fracture |
| S22088A | Other fracture of T11-T12 vertebra, initial encounter for closed fracture |
| S22088B | Other fracture of T11-T12 vertebra, initial encounter for open fracture |
| S22089A | Unspecified fracture of T11-T12 vertebra, initial encounter for closed fracture |
| S22089B | Unspecified fracture of T11-T12 vertebra, initial encounter for open fracture |
| S32000A | Wedge compression fracture of unspecified lumbar vertebra, initial encounter for closed fracture |
| S32000B | Wedge compression fracture of unspecified lumbar vertebra, initial encounter for open fracture |
| S32001A | Stable burst fracture of unspecified lumbar vertebra, initial encounter for closed fracture |
| S32001B | Stable burst fracture of unspecified lumbar vertebra, initial encounter for open fracture |
| S32002A | Unstable burst fracture of unspecified lumbar vertebra, initial encounter for closed fracture |
| S32002B | Unstable burst fracture of unspecified lumbar vertebra, initial encounter for open fracture |
| S32008A | Other fracture of unspecified lumbar vertebra, initial encounter for closed fracture |
| S32008B | Other fracture of unspecified lumbar vertebra, initial encounter for open fracture |
| S32009A | Unspecified fracture of unspecified lumbar vertebra, initial encounter for closed fracture |
| S32009B | Unspecified fracture of unspecified lumbar vertebra, initial encounter for open fracture |
| S32010A | Wedge compression fracture of first lumbar vertebra, initial encounter for closed fracture |
| S32010B | Wedge compression fracture of first lumbar vertebra, initial encounter for open fracture |
| S32011A | Stable burst fracture of first lumbar vertebra, initial encounter for closed fracture |
| S32011B | Stable burst fracture of first lumbar vertebra, initial encounter for open fracture |
| S32012A | Unstable burst fracture of first lumbar vertebra, initial encounter for closed fracture |
| S32012B | Unstable burst fracture of first lumbar vertebra, initial encounter for open fracture |
| S32018A | Other fracture of first lumbar vertebra, initial encounter for closed fracture |
| S32018B | Other fracture of first lumbar vertebra, initial encounter for open fracture |
| S32019A | Unspecified fracture of first lumbar vertebra, initial encounter for closed fracture |
| S32019B | Unspecified fracture of first lumbar vertebra, initial encounter for open fracture |
| S32020A | Wedge compression fracture of second lumbar vertebra, initial encounter for closed fracture |
| S32020B | Wedge compression fracture of second lumbar vertebra, initial encounter for open fracture |
| S32021A | Stable burst fracture of second lumbar vertebra, initial encounter for closed fracture |
| S32021B | Stable burst fracture of second lumbar vertebra, initial encounter for open fracture |
| S32022A | Unstable burst fracture of second lumbar vertebra, initial encounter for closed fracture |
| S32022B | Unstable burst fracture of second lumbar vertebra, initial encounter for open fracture |
| S32028A | Other fracture of second lumbar vertebra, initial encounter for closed fracture |
| S32028B | Other fracture of second lumbar vertebra, initial encounter for open fracture |
| S32029A | Unspecified fracture of second lumbar vertebra, initial encounter for closed fracture |
| S32029B | Unspecified fracture of second lumbar vertebra, initial encounter for open fracture |
| S32030A | Wedge compression fracture of third lumbar vertebra, initial encounter for closed fracture |
| S32030B | Wedge compression fracture of third lumbar vertebra, initial encounter for open fracture |
| S32031A | Stable burst fracture of third lumbar vertebra, initial encounter for closed fracture |
| S32031B | Stable burst fracture of third lumbar vertebra, initial encounter for open fracture |
| S32032A | Unstable burst fracture of third lumbar vertebra, initial encounter for closed fracture |
| S32032B | Unstable burst fracture of third lumbar vertebra, initial encounter for open fracture |
| S32038A | Other fracture of third lumbar vertebra, initial encounter for closed fracture |
| S32038B | Other fracture of third lumbar vertebra, initial encounter for open fracture |
| S32039A | Unspecified fracture of third lumbar vertebra, initial encounter for closed fracture |
| S32039B | Unspecified fracture of third lumbar vertebra, initial encounter for open fracture |
| S32040A | Wedge compression fracture of fourth lumbar vertebra, initial encounter for closed fracture |
| S32040B | Wedge compression fracture of fourth lumbar vertebra, initial encounter for open fracture |
| S32041A | Stable burst fracture of fourth lumbar vertebra, initial encounter for closed fracture |
| S32041B | Stable burst fracture of fourth lumbar vertebra, initial encounter for open fracture |
| S32042A | Unstable burst fracture of fourth lumbar vertebra, initial encounter for closed fracture |
| S32042B | Unstable burst fracture of fourth lumbar vertebra, initial encounter for open fracture |
| S32048A | Other fracture of fourth lumbar vertebra, initial encounter for closed fracture |
| S32048B | Other fracture of fourth lumbar vertebra, initial encounter for open fracture |
| S32049A | Unspecified fracture of fourth lumbar vertebra, initial encounter for closed fracture |
| S32049B | Unspecified fracture of fourth lumbar vertebra, initial encounter for open fracture |
| S32050A | Wedge compression fracture of fifth lumbar vertebra, initial encounter for closed fracture |
| S32050B | Wedge compression fracture of fifth lumbar vertebra, initial encounter for open fracture |
| S32051A | Stable burst fracture of fifth lumbar vertebra, initial encounter for closed fracture |
| S32051B | Stable burst fracture of fifth lumbar vertebra, initial encounter for open fracture |
| S32052A | Unstable burst fracture of fifth lumbar vertebra, initial encounter for closed fracture |
| S32052B | Unstable burst fracture of fifth lumbar vertebra, initial encounter for open fracture |
| S32058A | Other fracture of fifth lumbar vertebra, initial encounter for closed fracture |
| S32058B | Other fracture of fifth lumbar vertebra, initial encounter for open fracture |
| S32059A | Unspecified fracture of fifth lumbar vertebra, initial encounter for closed fracture |
| S32059B | Unspecified fracture of fifth lumbar vertebra, initial encounter for open fracture |
| S3210XA | Unspecified fracture of sacrum, initial encounter for closed fracture |
| S3210XB | Unspecified fracture of sacrum, initial encounter for open fracture |
| S32110A | Nondisplaced Zone I fracture of sacrum, initial encounter for closed fracture |
| S32110B | Nondisplaced Zone I fracture of sacrum, initial encounter for open fracture |
| S32111A | Minimally displaced Zone I fracture of sacrum, initial encounter for closed fracture |
| S32111B | Minimally displaced Zone I fracture of sacrum, initial encounter for open fracture |
| S32112A | Severely displaced Zone I fracture of sacrum, initial encounter for closed fracture |
| S32112B | Severely displaced Zone I fracture of sacrum, initial encounter for open fracture |
| S32119A | Unspecified Zone I fracture of sacrum, initial encounter for closed fracture |
| S32119B | Unspecified Zone I fracture of sacrum, initial encounter for open fracture |
| S32120A | Nondisplaced Zone II fracture of sacrum, initial encounter for closed fracture |
| S32120B | Nondisplaced Zone II fracture of sacrum, initial encounter for open fracture |
| S32121A | Minimally displaced Zone II fracture of sacrum, initial encounter for closed fracture |
| S32121B | Minimally displaced Zone II fracture of sacrum, initial encounter for open fracture |
| S32122A | Severely displaced Zone II fracture of sacrum, initial encounter for closed fracture |
| S32122B | Severely displaced Zone II fracture of sacrum, initial encounter for open fracture |
| S32129A | Unspecified Zone II fracture of sacrum, initial encounter for closed fracture |
| S32129B | Unspecified Zone II fracture of sacrum, initial encounter for open fracture |
| S32130A | Nondisplaced Zone III fracture of sacrum, initial encounter for closed fracture |
| S32130B | Nondisplaced Zone III fracture of sacrum, initial encounter for open fracture |
| S32131A | Minimally displaced Zone III fracture of sacrum, initial encounter for closed fracture |
| S32131B | Minimally displaced Zone III fracture of sacrum, initial encounter for open fracture |
| S32132A | Severely displaced Zone III fracture of sacrum, initial encounter for closed fracture |
| S32132B | Severely displaced Zone III fracture of sacrum, initial encounter for open fracture |
| S32139A | Unspecified Zone III fracture of sacrum, initial encounter for closed fracture |
| S32139B | Unspecified Zone III fracture of sacrum, initial encounter for open fracture |
| S3214XA | Type 1 fracture of sacrum, initial encounter for closed fracture |
| S3214XB | Type 1 fracture of sacrum, initial encounter for open fracture |
| S3215XA | Type 2 fracture of sacrum, initial encounter for closed fracture |
| S3215XB | Type 2 fracture of sacrum, initial encounter for open fracture |
| S3216XA | Type 3 fracture of sacrum, initial encounter for closed fracture |
| S3216XB | Type 3 fracture of sacrum, initial encounter for open fracture |
| S3217XA | Type 4 fracture of sacrum, initial encounter for closed fracture |
| S3217XB | Type 4 fracture of sacrum, initial encounter for open fracture |
| S3219XA | Other fracture of sacrum, initial encounter for closed fracture |
| S3219XB | Other fracture of sacrum, initial encounter for open fracture |
| S322XXA | Fracture of coccyx, initial encounter for closed fracture |
| S322XXB | Fracture of coccyx, initial encounter for open fracture |
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 |
|---|---|
| 169 | 339 |
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 401?
339 ICD-10-CM codes map to HCC 401 in the CMS PY2027 initial mapping, for example M4850XA Collapsed vertebra, not elsewhere classified, site unspecified, initial encounter for fracture; M4851XA Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, initial encounter for fracture; M4852XA Collapsed vertebra, not elsewhere classified, cervical region, initial encounter for fracture; M4853XA Collapsed vertebra, not elsewhere classified, cervicothoracic region, initial encounter for fracture. 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 401 add to a risk score?
The V28 relative factor for HCC 401 is 0.522 for a community, non-dual, aged beneficiary, 0.622 for full-benefit dual aged, 0.605 for non-dual disabled and 0.231 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 401 count together with related categories?
HCC 401 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 401 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.