HCC 213 Cardio-Respiratory Failure: What Still Captures in V28

You searched hcc 213 because the chart says respiratory failure, ARDS, acute pulmonary edema, cardiac arrest, ventricular fibrillation or flutter, or shock. You need to know whether V28 still pays, which codes are in the family, and what trumps it.

Open the member-code list and segment table on the HCC 213 card. Last verified against those CMS files on the card (reviewed 2026-05-30). This page is the desk walk for that card. It is not an IPPS story and not an NCD story.

*Current as of August 19, 2026. Category name, CNA factor, 36-code count, hierarchy, and every ICD-10-CM member code come from the CMS-HCC V28 PY2026 model software and the 2026 Final ICD-10-CM Mappings, as published on the HCC 213 card. Sequencing rules cite the FY 2026 ICD-10-CM Official Guidelines, Chapter 10, Section I.C.10.b. Verify against the current CMS files before you rely on it.*

Quick answer

Under CMS-HCC V28 for payment year 2026 (100% V28, V24 retired for payment), HCC 213 is Cardio-Respiratory Failure and Shock. The community non-dual aged relative factor is 0.370 (the PY2026 relative-factor file publishes it as 0.37). Thirty-six payable ICD-10-CM codes map to it. In the V28 hierarchy, HCC 211 (Respirator Dependence/Tracheostomy Status/Complications) and HCC 212 (Respiratory Arrest) supersede HCC 213. If 211 or 212 is also present and supported, 213 does not add a second payment factor.

This is a payment-category fact from the CMS-HCC V28 PY2026 model files. It is not an IPPS MS-DRG severity change and not a CMS-HCC model update beyond V28 itself.

What HCC 213 is for at the desk

The category is a family, not one code. J96.01 (acute respiratory failure with hypoxia) and J96.11 (chronic respiratory failure with hypoxia) both map to HCC 213. So do I46.9 (cardiac arrest, cause unspecified) and R57.0 (cardiogenic shock). Do not assume "unspecified" means "no HCC." On this card, J96.90 through J96.92 and R57.9 still map. Unspecified is an audit and MEAT problem, not a mapping problem.

COPD without respiratory failure is a different category. J44 codes that describe COPD live in HCC 280 on the COPD guide. A patient can have both: J44.1 for the lung disease (280) and J96.21 for acute-on-chronic respiratory failure (213). Those are different hierarchy groups. One does not trump the other. COPD without a supported J96 is 280 only.

Hierarchy: when 213 disappears

Trumping only happens inside the cardio-respiratory failure group.

1. Code and support the highest category the encounter actually documents.

2. If the record supports respirator dependence / tracheostomy complications (HCC 211) or respiratory arrest (HCC 212), that factor replaces 213. You did not "lose" 213. The model already priced the more severe state.

3. If the record only supports respiratory failure, ARDS, cardiac arrest, or shock, and not 211 or 212, HCC 213 is the survivor.

Do not spend the encounter hunting a lower-severity 213 code after 211 or 212 is already clean. Do spend it confirming whether 211 or 212 is actually in the note. The hierarchy explainer is the site-wide rulebook. This post is the 211 / 212 / 213 desk card.

Look up the current encounter codes in the encoder before you finalize. Hierarchy is applied in the model, not by deleting the lower ICD-10 code from the claim.

Adult codes that map (from the V28 213 card)

These are the adult (and unspecified-shock) member codes published on the HCC 213 card for PY2026. Do not add codes from memory.

Respiratory failure (J96)

Other adult respiratory

Arrest and arrhythmia

Shock

That is 21 adult codes. The remaining 15 of the 36 are the perinatal codes on the card: P22.0, P26.0, P26.1, P26.8, P26.9, P27.0, P27.1, P27.8, P27.9, P28.0, P28.10, P28.11, P28.19, P28.5, and P29.81. If you are coding an adult Medicare Advantage encounter, you will almost never use those. Do not borrow a newborn code to "find" 213. P22.1, P22.8, and P22.9 are not on this card.

If a code is not on that list, it does not map to HCC 213 in V28 PY2026. Check the ICD-10 to HCC map.

Guidelines vs payment: I.C.10.b is sequencing, not RAF

FY 2026 ICD-10-CM Official Guidelines, Chapter 10, Section I.C.10.b (Acute Respiratory Failure) tell you when J96.0- or J96.2- may be principal or first-listed and when respiratory failure is additional. That is ICD-10 sequencing for the encounter. It does not change which CMS-HCC category the code maps to.

Desk split:

Chronic respiratory failure (J96.1x) is still HCC 213. The guideline section title is "Acute Respiratory Failure." Do not read that title as "chronic J96 does not pay."

Code the underlying lung or cardiac disease when the classification requires it. That other code may be HCC 280 (COPD), HCC 226 (chronic or unspecified heart failure), another heart-failure category, or unmapped. It does not replace the J96 to 213 map. Heart failure lives in a separate hierarchy.

MEAT that makes 213 stick

A problem-list row of "chronic respiratory failure" from last year is not enough. The encounter has to show monitoring, evaluation, assessment, or treatment this visit. See MEAT criteria and problem lists do not validate HCCs. MEAT is the training mnemonic. The authorities are the Official Guidelines and the record from the date of service.

What the note usually needs for J96 / I46 / R57:

If acuity or hypoxia/hypercapnia is missing and you cannot assign a valid J96 character, query. Do not pick J96.90 to "save" 213 unless the documentation actually supports unspecified respiratory failure.

R57.9 (shock, unspecified) maps to 213 on the PY2026 card. It is also the first code an auditor will ask you to defend. If the record supports cardiogenic shock, use R57.0. If it supports hypovolemic or other specified shock, check the map. Those codes are not on the 213 member list.

Common misses (no invented "top audit" counts)

1. Coding J44 and stopping. COPD exacerbation without a supported J96 does not create HCC 213.

2. Assuming unspecified J96 does not map. J96.9x maps. The fight is MEAT and whether a more specific J96 is supported.

3. Recapturing 213 after 211 or 212 is already on the same year. The hierarchy will zero 213. Confirm 211 or 212 instead.

4. Using a perinatal P code on an adult chart. Those codes are in the 36 because the CMS file includes them. They are not an adult workaround.

5. Leading with I.C.10.b and forgetting the map. Principal-diagnosis rules do not delete HCC 213. Wrong ICD-10 assignment does.

How to check it in two minutes

1. Find the diagnosis the provider actually assessed today.

2. Assign the ICD-10-CM code from the Tabular and Index, then I.C.10.b if J96 acuity or sequencing is in play.

3. Look the code up on HCC Buddy. If it is a 213 member, confirm MEAT.

4. Look at the rest of the year: is 211 or 212 already supported?

5. Model the survivor in the RAF calculator if you need the post-hierarchy factor.

Related

Disclaimer

This article is for professional and educational use only. It is not coding, billing, legal, or medical advice. Verify every code, HCC map, and sequencing rule against current official CMS, ICD-10-CM, and AHA Coding Clinic guidance and your payer's policy before you assign it. Reading it creates no provider, patient, or advisory relationship.

Mappings and the 0.370 CNA factor are CMS-HCC V28 PY2026, as published on the HCC 213 card (CMS model software and ICD-10-CM mapping file). Sequencing rules: FY 2026 ICD-10-CM Official Guidelines I.C.10.b. Not a CMS-HCC model change beyond V28. Not an IPPS or NCD story.

By the HCC Buddy Coding Team.

Sources

HCC 213 card, CMS-HCC V28 PY2026 (category name, CNA 0.37 / 0.370, 36 codes, hierarchy; last reviewed May 30, 2026)

CMS 2026 Model Software / Final ICD-10-CM Mappings

ICD-10-CM Official Guidelines for Coding and Reporting, FY 2026, Chapter 10, Section I.C.10.b; Section II.C

CMS-HCC V28 PY2026 relative factors and hierarchy files (HCC 213 COMMUNITY_NA 0.37; HCC 211 and HCC 212 supersede 213)