Risk Adjustment Eligible CPT Codes, 2026 Reference

The Quick Answer

Check the exact CPT or HCPCS code in the applicable CMS Medicare Risk Adjustment Eligible CPT/HCPCS file, then apply the payment-year and record-type filtering instructions. A code range, service label, telehealth modifier, or benefit-coverage decision does not establish risk-adjustment eligibility by itself. Diagnosis support and ICD-10-CM reportability remain separate checks.

Why Encounter Eligibility Matters More Than Most Coders Realize

Risk adjustment coding accuracy gets most of the attention in HCC training. Coders spend hours learning ICD-10 specificity, MEAT documentation, hierarchy rules, and V28 mappings. But none of that work matters if the diagnoses come from an encounter type that CMS does not accept for risk adjustment data submission.

Source eligibility is separate from diagnosis coding. Use the applicable CMS filtering rules for the record type and data period; do not decide eligibility from a broad label such as imaging, pathology, or care management.

CMS publishes annual Medicare risk-adjustment eligible CPT/HCPCS files. Select the file for the relevant service-date period and check the applicable payment-year submission and filtering instructions. Keep the rules for different record types and programs separate.

RAPS and Encounter Data: Check the Payment-Year Policy

Use the payment-year policy to determine which submission pathways and filtering rules apply.

RAPS (Risk Adjustment Processing System) is the legacy submission pathway. Plans submit diagnosis clusters, combinations of a beneficiary ID, provider information, dates of service, and ICD-10-CM codes, directly to RAPS. RAPS uses its own filtering logic to accept or reject submitted diagnoses based on encounter type.

EDPS (Encounter Data Processing System) receives encounter records from which CMS identifies eligible diagnoses. Its record-level filtering is distinct from the legacy RAPS submission pathway; do not assume identical rules.

The CY2026 Rate Announcement, Section G, uses eligible diagnoses from encounter data and FFS claims for non-PACE organizations. PACE has a separate transition policy. Do not apply a blanket RAPS/EDPS blend or assume identical filtering across programs.

Check the Record, Provider and Service Together

Determine the applicable record type, provider eligibility and service requirements before deciding whether a diagnosis is an allowable risk-adjustment input. Medical-record audit rules, encounter-data filtering and Medicare benefit coverage answer different questions.

Use the applicable CMS provider and record-source instructions. Eligibility does not follow solely from a professional title or whether a service is billed as E/M.

Verify an Exact Code in the CMS File

1. Open the CMS eligible CPT/HCPCS source page and select the file for the relevant service-date year. The page provides a 2026 file and separate historical files.

2. Search the complete code. Do not treat a numeric range as an eligibility list or rely on a code deleted in a later edition.

3. Apply the CMS filtering instructions for the record type and payment year, including other relevant service lines. A code's presence in the file does not alone establish that a medical record supports a submitted diagnosis.

4. Confirm the provider, encounter and documentation requirements for the submission. Keep coverage and payment status separate from risk-adjustment source eligibility.

Telehealth Requires Its Own Source Check

Do not use a modifier, place of service, or a general Medicare telehealth coverage list as a substitute for the risk-adjustment eligibility file and program instructions. Check the applicable year and modality. Medicare Advantage and HHS-operated risk adjustment are separate programs; their rules must not be blended.

This article does not reproduce a blanket allowed or excluded code range. Use the official file and approved submission guidance for the specific record.

Practical Tips for Coders

1. Check the source before submission. Verify the exact service code and applicable CMS filtering instructions using the official file; do not classify an entire service category as eligible or excluded.

2. Keep the diagnosis tied to its actual record. Do not move a diagnosis to another claim simply to obtain eligibility. Follow the applicable documentation, linkage and submission requirements.

3. Check telehealth separately. Verify the program, service-date period, exact code, modality and applicable source requirements. Benefit coverage does not establish risk-adjustment eligibility.

4. Review wellness-visit diagnoses individually. An eligible visit does not make every problem-list diagnosis reportable or create an annual MEAT requirement.

5. Review multiple service lines under the actual filtering rules. Do not assume the E/M line is always the only eligible source or attach a diagnosis to a different service for its HCC effect.

6. Stay current with CMS updates. The eligible encounter list is updated annually. Telehealth eligibility in particular has been in flux since 2020 and continues to evolve. Check the CMS risk-adjustment hub for the current payment year's Eligible Encounter guidance, and cross-reference any CPT or ICD-10 question against the CMS ICD-10-CM code set.

How HCC Buddy Helps

> RAF Calculator: The RAF Calculator supports CMS-HCC V28 for Payment Year 2026 and requires complete member context. HCC Buddy shows a score only after the server confirms the required source and calculation checks. If a check is unavailable or does not pass, no score is shown.

Knowing which encounters are eligible is the first step. The next step is ensuring that every eligible encounter captures every documented, supportable HCC diagnosis. HCC Buddy's ICD-10 Encoder lets you look up any diagnosis code and instantly see its HCC mapping, so you can prioritize coding on eligible encounters that carry HCC value.

Risk adjustment coding is a chain: eligible encounter, documented diagnosis, accurate ICD-10 code, valid HCC mapping. If any link breaks, the RAF value is lost. Start with the encounter eligibility check, and work forward from there.