Skip to main content

Substance use HCCs in CMS-HCC V28 (HCC 135-139)

The substance use group of the CMS-HCC V28 model holds 5 payment categories (HCC 135, 136, 137, 138, 139): drug and alcohol use disorders by complication and severity. 465 ICD-10-CM codes map to them in the payment year 2027 initial mapping. Community, non-dual, aged factors run from 0.242 (HCC 139) to 0.424 (HCC 137). One hierarchy ranks HCC 135 > 136 > 137 > 138 > 139, so a member is paid for at most one category in the chain.

Compiled from CMS files by the QuickIntell RCM Editorial Team · Data effective · Method: reference methodology · Report a data correction

Data currency: ICD-10-CM to HCC mapping: PY2027 initial ICD-10-CM mappings (dates of service 2026) (payment year 2027); CMS-HCC V28 model software: CMS-HCC V28 software V2826.115.T2 (PY2027 initial) (payment year 2027). Next CMS release: PY2028 advance notice (February 2027) and the PY2027 midyear final mapping (spring 2027).

Payment categories
5
Mapped ICD-10-CM codes
465
Factor range (CNA)
0.242 to 0.424
Hierarchies in the group
1
CMS hierarchy group "SUD"

Categories and relative factors

Each factor is added to the member's demographic factors when the category is documented in the data collection year. Community, non-dual, aged (CNA) is the largest segment; the disabled (CND) and long-term institutional (INS) segments are estimated separately, which is why the same category is worth a different amount for each.

CMS-HCC V28 substance use categories with relative factors
HCCCategoryCodesCNACNDINS
HCC 135Drug Use with Psychotic Complications970.4240.6370.297
HCC 136Alcohol Use with Psychotic Complications190.4240.6370.297
HCC 137Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications3080.4240.3650.297
HCC 138Drug Use Disorder, Mild, Uncomplicated, Except Cannabis140.4230.2640.297
HCC 139Alcohol Use Disorder, Moderate/Severe, or Alcohol Use with Specified Non-Psychotic Complications270.2420.2070.000

Hierarchy inside the group

The V28 hierarchy macro ranks related categories so that a member with codes in several of them is paid only for the higher-ranked one. Each category drops only the categories its own macro entry lists.

Read each chain left to right: every category drops every category to its right, so a member is paid for at most one category per chain.

  • HCC 135 (Drug Use with Psychotic Complications) > HCC 136 (Alcohol Use with Psychotic Complications) > HCC 137 (Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications) > HCC 138 (Drug Use Disorder, Mild, Uncomplicated, Except Cannabis) > HCC 139 (Alcohol Use Disorder, Moderate/Severe, or Alcohol Use with Specified Non-Psychotic Complications)

Interaction terms that involve this group

V28 pays an extra factor when two condition groups are documented together, on top of each category's own factor. A blank cell means the segment carries no such term.

V28 interaction factors involving substance use categories
InteractionCNACNDINS
Substance use disorder and psychiatric condition0.087

ICD-10-CM code families

Where the mapped codes concentrate. A family with many codes is usually where specificity matters most: the category only counts when the documented diagnosis supports the exact code reported.

Three-character ICD-10-CM categories with the most codes in the substance use group
ICD-10-CM categoryMapped codes
F1961
F1356
F1046
F1446
F1546
F1143
F1638
F1837

Where these codes sat in V24

The payment year 2025 mapping lists the V24 and V28 category for the same codes. 26 codes in this group had no V24 payment category. The main V24 sources are below; the crosswalk report covers every category.

V24 categories behind the substance use V28 categories (PY2025 mapping)
V24 HCCV24 categoryCodes
55Substance Use Disorder, Moderate/Severe, or Substance Use with Complications308
54Substance Use with Psychotic Complications116
56Substance Use Disorder, Mild, Except Alcohol and Cannabis14

The CMS-HCC V24 vs V28 crosswalk shows the codes that lost or gained payment status across all categories.

Inpatient MS-DRGs that use these diagnoses

Appendix B of the v44 MS-DRG Definitions Manual names the DRGs whose logic uses each diagnosis. The same documentation supports the inpatient group and, for Medicare Advantage members, the risk score.

MS-DRGs whose logic lists the most substance use HCC codes
MS-DRGTitleShared codes
DRG 894Alcohol, Drug Abuse or Dependence, Left AMA398
DRG 895Alcohol, Drug Abuse or Dependence with Rehabilitation Therapy398
DRG 896Alcohol, Drug Abuse or Dependence without Rehabilitation Therapy with MCC398
DRG 897Alcohol, Drug Abuse or Dependence without Rehabilitation Therapy without MCC398
DRG 917Poisoning and Toxic Effects of Drugs with MCC40
DRG 918Poisoning and Toxic Effects of Drugs without MCC40
DRG 791Prematurity with Major Problems37
DRG 793Full Term Neonate with Major Problems37

FY2027 code changes in this group

The October 1, 2026 ICD-10-CM update deleted no code mapped to this group, so its code lists carry into FY2027 unchanged until CMS posts a mapping for the new code set. The FY2027 code changes report lists every new and deleted code.

Where QuickIntell fits for substance use HCCs

An HCC counts only when the visit note supports it. QuickScribe captures the encounter documentation, and QuickCode supports qualified coder review and documentation clarification before diagnoses are submitted.

See QuickScribe for visit documentationSee QuickCode for coder reviewBook a meeting

Frequently asked questions

Which HCCs are in the V28 substance use group?

HCC 135 (Drug Use with Psychotic Complications, 97 codes, factor 0.424); HCC 136 (Alcohol Use with Psychotic Complications, 19 codes, factor 0.424); HCC 137 (Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications, 308 codes, factor 0.424); HCC 138 (Drug Use Disorder, Mild, Uncomplicated, Except Cannabis, 14 codes, factor 0.423); HCC 139 (Alcohol Use Disorder, Moderate/Severe, or Alcohol Use with Specified Non-Psychotic Complications, 27 codes, factor 0.242).

Which substance use HCC has the most mapped ICD-10-CM codes?

HCC 137, Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications, with 308 codes in the PY2027 initial mapping; across the group the largest code families are F19 (61), F13 (56), F10 (46), F14 (46).

Where did the substance use codes sit in the V24 model?

In the PY2025 mapping, which carries both models, 464 code-to-category links point to this group; 26 of those codes had no V24 payment category. The main V24 sources were HCC 55 (Substance Use Disorder, Moderate/Severe, or Substance Use with Complications, 308), HCC 54 (Substance Use with Psychotic Complications, 116), HCC 56 (Substance Use Disorder, Mild, Except Alcohol and Cannabis, 14).

Do substance use HCCs interact with other conditions in V28?

Yes. Substance use disorder and psychiatric condition adds 0.087 (community, non-dual, disabled; the term exists only for disabled community members). Each term is added on top of the category factors when both conditions are documented.

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.

Disclaimer

Factors, hierarchies and mappings are reproduced from the CMS risk adjustment model files as an operational reference. The group is a navigation aid built from the V28 hierarchy; CMS pays categories, not groups. Payment depends on the plan's base rate, normalization, the coding intensity adjustment and the enrollee's segment. Not legal, clinical or billing advice.

Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.