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_HCC81 | 0.244 |
| Community, non-dual, disabled | CND_HCC81 | 0.285 |
| Community, full-benefit dual, aged | CFA_HCC81 | 0.201 |
| Community, full-benefit dual, disabled | CFD_HCC81 | 0.286 |
| Community, partial-benefit dual, aged | CPA_HCC81 | 0.205 |
| Community, partial-benefit dual, disabled | CPD_HCC81 | 0.237 |
| Long-term institutional | INS_HCC81 | 0.258 |
Hierarchy
Hierarchical condition categories pay only the most severe manifestation of a disease. When HCC 77 (Intestine Transplant Status/Complications) or HCC 80 (Crohn's Disease (Regional Enteritis)) is also documented for the same beneficiary, HCC 81 is dropped from the score.
ICD-10-CM codes that map to HCC 81
49 codes map to this category in the PY2027 initial mapping. Descriptions are the CMS mapping descriptions for the FY2026 code set; a code that is deleted or split in the October code update stays valid for dates of service before the change.
| ICD-10-CM | Description |
|---|---|
| K5100 | Ulcerative (chronic) pancolitis without complications |
| K51011 | Ulcerative (chronic) pancolitis with rectal bleeding |
| K51012 | Ulcerative (chronic) pancolitis with intestinal obstruction |
| K51013 | Ulcerative (chronic) pancolitis with fistula |
| K51014 | Ulcerative (chronic) pancolitis with abscess |
| K51018 | Ulcerative (chronic) pancolitis with other complication |
| K51019 | Ulcerative (chronic) pancolitis with unspecified complications |
| K5120 | Ulcerative (chronic) proctitis without complications |
| K51211 | Ulcerative (chronic) proctitis with rectal bleeding |
| K51212 | Ulcerative (chronic) proctitis with intestinal obstruction |
| K51213 | Ulcerative (chronic) proctitis with fistula |
| K51214 | Ulcerative (chronic) proctitis with abscess |
| K51218 | Ulcerative (chronic) proctitis with other complication |
| K51219 | Ulcerative (chronic) proctitis with unspecified complications |
| K5130 | Ulcerative (chronic) rectosigmoiditis without complications |
| K51311 | Ulcerative (chronic) rectosigmoiditis with rectal bleeding |
| K51312 | Ulcerative (chronic) rectosigmoiditis with intestinal obstruction |
| K51313 | Ulcerative (chronic) rectosigmoiditis with fistula |
| K51314 | Ulcerative (chronic) rectosigmoiditis with abscess |
| K51318 | Ulcerative (chronic) rectosigmoiditis with other complication |
| K51319 | Ulcerative (chronic) rectosigmoiditis with unspecified complications |
| K5140 | Inflammatory polyps of colon without complications |
| K51411 | Inflammatory polyps of colon with rectal bleeding |
| K51412 | Inflammatory polyps of colon with intestinal obstruction |
| K51413 | Inflammatory polyps of colon with fistula |
| K51414 | Inflammatory polyps of colon with abscess |
| K51418 | Inflammatory polyps of colon with other complication |
| K51419 | Inflammatory polyps of colon with unspecified complications |
| K5150 | Left sided colitis without complications |
| K51511 | Left sided colitis with rectal bleeding |
| K51512 | Left sided colitis with intestinal obstruction |
| K51513 | Left sided colitis with fistula |
| K51514 | Left sided colitis with abscess |
| K51518 | Left sided colitis with other complication |
| K51519 | Left sided colitis with unspecified complications |
| K5180 | Other ulcerative colitis without complications |
| K51811 | Other ulcerative colitis with rectal bleeding |
| K51812 | Other ulcerative colitis with intestinal obstruction |
| K51813 | Other ulcerative colitis with fistula |
| K51814 | Other ulcerative colitis with abscess |
| K51818 | Other ulcerative colitis with other complication |
| K51819 | Other ulcerative colitis with unspecified complications |
| K5190 | Ulcerative colitis, unspecified, without complications |
| K51911 | Ulcerative colitis, unspecified with rectal bleeding |
| K51912 | Ulcerative colitis, unspecified with intestinal obstruction |
| K51913 | Ulcerative colitis, unspecified with fistula |
| K51914 | Ulcerative colitis, unspecified with abscess |
| K51918 | Ulcerative colitis, unspecified with other complication |
| K51919 | Ulcerative colitis, unspecified with unspecified complications |
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 |
|---|---|
| 35 | 49 |
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 81?
49 ICD-10-CM codes map to HCC 81 in the CMS PY2027 initial mapping, for example K5100 Ulcerative (chronic) pancolitis without complications; K51011 Ulcerative (chronic) pancolitis with rectal bleeding; K51012 Ulcerative (chronic) pancolitis with intestinal obstruction; K51013 Ulcerative (chronic) pancolitis with fistula. 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 81 add to a risk score?
The V28 relative factor for HCC 81 is 0.244 for a community, non-dual, aged beneficiary, 0.201 for full-benefit dual aged, 0.285 for non-dual disabled and 0.258 for long-term institutional members. A factor of 1.000 equals the expected annual cost of an average beneficiary, so the category's share of the payment follows the plan's base rate for that segment.
Does HCC 81 count together with related categories?
No. Within a hierarchy only the most severe category is paid. HCC 81 is dropped when HCC 77 (Intestine Transplant Status/Complications) or HCC 80 (Crohn's Disease (Regional Enteritis)) is also present.
What has to be documented for HCC 81 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.