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_HCC94 | 0.268 |
| Community, non-dual, disabled | CND_HCC94 | 0.239 |
| Community, full-benefit dual, aged | CFA_HCC94 | 0.237 |
| Community, full-benefit dual, disabled | CFD_HCC94 | 0.250 |
| Community, partial-benefit dual, aged | CPA_HCC94 | 0.224 |
| Community, partial-benefit dual, disabled | CPD_HCC94 | 0.196 |
| Long-term institutional | INS_HCC94 | 0.297 |
Hierarchy
Hierarchical condition categories pay only the most severe manifestation of a disease. When HCC 93 (Rheumatoid Arthritis and Other Specified Inflammatory Rheumatic Disorders) is also documented for the same beneficiary, HCC 94 is dropped from the score.
ICD-10-CM codes that map to HCC 94
71 codes map to this category in the PY2027 initial mapping, concentrated in the M02 (24), M12 (24), M32 (9), M31 (5), M04 (4), M30 (3) 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 |
|---|---|
| M0230 | Reiter's disease, unspecified site |
| M02311 | Reiter's disease, right shoulder |
| M02312 | Reiter's disease, left shoulder |
| M02319 | Reiter's disease, unspecified shoulder |
| M02321 | Reiter's disease, right elbow |
| M02322 | Reiter's disease, left elbow |
| M02329 | Reiter's disease, unspecified elbow |
| M02331 | Reiter's disease, right wrist |
| M02332 | Reiter's disease, left wrist |
| M02339 | Reiter's disease, unspecified wrist |
| M02341 | Reiter's disease, right hand |
| M02342 | Reiter's disease, left hand |
| M02349 | Reiter's disease, unspecified hand |
| M02351 | Reiter's disease, right hip |
| M02352 | Reiter's disease, left hip |
| M02359 | Reiter's disease, unspecified hip |
| M02361 | Reiter's disease, right knee |
| M02362 | Reiter's disease, left knee |
| M02369 | Reiter's disease, unspecified knee |
| M02371 | Reiter's disease, right ankle and foot |
| M02372 | Reiter's disease, left ankle and foot |
| M02379 | Reiter's disease, unspecified ankle and foot |
| M0238 | Reiter's disease, vertebrae |
| M0239 | Reiter's disease, multiple sites |
| M041 | Periodic fever syndromes |
| M042 | Cryopyrin-associated periodic syndromes |
| M048 | Other autoinflammatory syndromes |
| M049 | Autoinflammatory syndrome, unspecified |
| M064 | Inflammatory polyarthropathy |
| M1200 | Chronic postrheumatic arthropathy [Jaccoud], unspecified site |
| M12011 | Chronic postrheumatic arthropathy [Jaccoud], right shoulder |
| M12012 | Chronic postrheumatic arthropathy [Jaccoud], left shoulder |
| M12019 | Chronic postrheumatic arthropathy [Jaccoud], unspecified shoulder |
| M12021 | Chronic postrheumatic arthropathy [Jaccoud], right elbow |
| M12022 | Chronic postrheumatic arthropathy [Jaccoud], left elbow |
| M12029 | Chronic postrheumatic arthropathy [Jaccoud], unspecified elbow |
| M12031 | Chronic postrheumatic arthropathy [Jaccoud], right wrist |
| M12032 | Chronic postrheumatic arthropathy [Jaccoud], left wrist |
| M12039 | Chronic postrheumatic arthropathy [Jaccoud], unspecified wrist |
| M12041 | Chronic postrheumatic arthropathy [Jaccoud], right hand |
| M12042 | Chronic postrheumatic arthropathy [Jaccoud], left hand |
| M12049 | Chronic postrheumatic arthropathy [Jaccoud], unspecified hand |
| M12051 | Chronic postrheumatic arthropathy [Jaccoud], right hip |
| M12052 | Chronic postrheumatic arthropathy [Jaccoud], left hip |
| M12059 | Chronic postrheumatic arthropathy [Jaccoud], unspecified hip |
| M12061 | Chronic postrheumatic arthropathy [Jaccoud], right knee |
| M12062 | Chronic postrheumatic arthropathy [Jaccoud], left knee |
| M12069 | Chronic postrheumatic arthropathy [Jaccoud], unspecified knee |
| M12071 | Chronic postrheumatic arthropathy [Jaccoud], right ankle and foot |
| M12072 | Chronic postrheumatic arthropathy [Jaccoud], left ankle and foot |
| M12079 | Chronic postrheumatic arthropathy [Jaccoud], unspecified ankle and foot |
| M1208 | Chronic postrheumatic arthropathy [Jaccoud], other specified site |
| M1209 | Chronic postrheumatic arthropathy [Jaccoud], multiple sites |
| M300 | Polyarteritis nodosa |
| M302 | Juvenile polyarteritis |
| M308 | Other conditions related to polyarteritis nodosa |
| M315 | Giant cell arteritis with polymyalgia rheumatica |
| M316 | Other giant cell arteritis |
| M317 | Microscopic polyangiitis |
| M318 | Other specified necrotizing vasculopathies |
| M319 | Necrotizing vasculopathy, unspecified |
| M3210 | Systemic lupus erythematosus, organ or system involvement unspecified |
| M3211 | Endocarditis in systemic lupus erythematosus |
| M3212 | Pericarditis in systemic lupus erythematosus |
| M3213 | Lung involvement in systemic lupus erythematosus |
| M3214 | Glomerular disease in systemic lupus erythematosus |
| M3215 | Tubulo-interstitial nephropathy in systemic lupus erythematosus |
| M3219 | Other organ or system involvement in systemic lupus erythematosus |
| M328 | Other forms of systemic lupus erythematosus |
| M329 | Systemic lupus erythematosus, unspecified |
| M352 | Behcet's disease |
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 |
|---|---|
| 40 | 69 |
| 108 | 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 94?
71 ICD-10-CM codes map to HCC 94 in the CMS PY2027 initial mapping, for example M0230 Reiter's disease, unspecified site; M02311 Reiter's disease, right shoulder; M02312 Reiter's disease, left shoulder; M02319 Reiter's disease, unspecified shoulder. 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 94 add to a risk score?
The V28 relative factor for HCC 94 is 0.268 for a community, non-dual, aged beneficiary, 0.237 for full-benefit dual aged, 0.239 for non-dual disabled and 0.297 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 94 count together with related categories?
No. Within a hierarchy only the most severe category is paid. HCC 94 is dropped when HCC 93 (Rheumatoid Arthritis and Other Specified Inflammatory Rheumatic Disorders) is also present.
What has to be documented for HCC 94 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.