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CMS-HCC V28 Guide 2026: 115 HCCs, Weights, and Free Lookup

CMS-HCC V28 is the 2026 Medicare Advantage risk adjustment model. Payment year 2026 is the first year without a V24 blend, which means every HCC on every submitted claim is now evaluated against the V28 category map, the V28 hierarchy rules, and the 2026 V28 coefficient set published in the April 2025 CMS Rate Announcement.

This hub covers what V28 is, what changed from V24, the full 2026 HCC list, which category families gained or lost RAF weight, and how coders should retool chart review workflows for 100% V28.

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Quick answer

V28 contains 115 payment HCC categories, a 67/33 → 33/67 → 0/100 V24/V28 phase-in from payment year 2024 to 2026, and a 2026 coefficient set that is on average 3.2% lower than V24 for the same condition list. The RAF impact per contract varies widely, diabetes-heavy panels came out slightly ahead, mental-health-heavy panels lost the most ground, and vascular-disease categories lost some of their biggest coefficient weights entirely.

Video lesson

2,261 Codes Stopped Paying in 2026 (CMS-HCC V28 Explained)

Payment year 2026 runs entirely on CMS-HCC V28: 115 payment categories, 2,261 formerly-mapped codes with no V28 mapping, 225 new gains, and reweighted diabetes and obesity codes — what changed and what coders do about it.

Key takeaways

  • 2026 is the first payment year that runs entirely on CMS-HCC V28 — the V24 blend is over. V24 had 86 payment categories; V28 has 115.
  • 7,794 diagnosis codes risk adjust in both models, 2,261 codes that mapped under V24 map to nothing in V28, and 225 codes gained a mapping.
  • The malnutrition family (E43, E44.0, E44.1, R64) mapped to V24 HCC 21 at 0.455 — in V28 it maps to nothing. Unspecified codes like I73.9 and I20.9 also dropped out while specific siblings such as I20.0 (HCC 229) still pay.
  • Weights moved even for surviving codes: E11.9 went from 0.105 (V24) to 0.166 (V28), E11.22 came down from 0.302 to the same 0.166, and E66.01 dropped from 0.25 to 0.186.
  • The playbook: rebuild recapture and suspect lists against V28, stop settling for unspecified codes, and re-aim audit focus at specificity calls.
Read the full transcript

Meet Rosa. Nine years coding Medicare Advantage charts, same desk, same coffee, same stack of notes. This morning nothing about her job looks different. But underneath her, the model just finished changing. 2026 is the first payment year that runs entirely on CMS-HCC V28. The phase-in is over. There is no more blending with V24.

First, the shape of the model changed. V24 had 86 payment categories. V28 has 115. Categories were renumbered, split, and consolidated. So a diagnosis that used to live at HCC 18 might live at HCC 37 now. Same disease, new address, and often a new weight on the mailbox.

Now the part that hits Rosa directly: which codes still pay. Working from the CMS mappings, 7,794 diagnosis codes risk adjust in both models. But 2,261 codes that mapped under V24 map to nothing in V28. They fell out of the payment model entirely. Only 225 went the other way and gained a mapping. The result is a smaller, more specific payment code set.

Here is the loudest example. Protein-calorie malnutrition. Under V24, codes like E43, E44.0, E44.1, and R64, cachexia, all mapped to HCC 21, worth 0.455. In V28, that entire family maps to nothing. Malnutrition still matters clinically, and it still belongs in the record when the chart supports it. It just no longer moves the risk score.

And the same pattern repeats across the unspecified codes coders leaned on for years. I73.9, peripheral vascular disease unspecified, paid under V24. Gone in V28. I20.9, unspecified angina: gone. But I20.0, unstable angina, still pays, as HCC 229. Acute kidney failure, the N17 family: gone. The pattern is consistent. Vague codes stopped paying. Specific codes still do.

A few families went the other way. Benign carcinoid tumors, the D3A.00 family, map in V28 and never did under V24. There are 225 of these gains in total. Worth a scan if those diagnoses show up in your population.

Even the codes that kept a mapping changed value. Uncomplicated type 2 diabetes, E11.9, went up: 0.105 under V24, 0.166 under V28. But diabetes with chronic kidney disease, E11.22, came down, from 0.302 to that same 0.166. V28 flattened the diabetes categories to one weight. Heart failure went up a little. And morbid obesity, E66.01, dropped from 0.25 to 0.186.

So what does Rosa actually do with this? Three things. One: rebuild the recapture and suspect lists against V28, because a list built on V24 is chasing codes that no longer pay. Two: retire the reflex of settling for unspecified. If the chart supports the specific code, the specific code is the one that risk adjusts. Three: re-aim the audit focus. The diabetes queries you used to fight over are worth less now. The heart failure and specificity calls are worth more.

If you want to sanity check any single code, the mapping and both models' weights are free to look up on our site, and the RAF calculator shows V24 and V28 side by side, on the same patient. That is V28 in 2026. Fewer vague codes, more categories, and a model that finally pays for the specificity you were already trained to document. Thanks for watching.

115

payment HCC categories in the CMS-HCC V28 model for payment year 2026, per the CMS V28 risk adjustment model files.

8,299

payable ICD-10-CM diagnosis codes map to a CMS-HCC V28 payment category for 2026, counted directly from the CMS ICD-10-CM mapping file.

Verified current to CMS-HCC V28, payment year 2026. Last reviewed May 10, 2026.

What V28 is, and what it replaces

CMS uses Hierarchical Condition Category (HCC) models to set the capitation that Medicare Advantage plans receive per enrollee per month. Each HCC is a clinical category tied to a RAF (risk adjustment factor) coefficient; higher-RAF enrollees generate higher capitation. V24 was the model in use from payment year 2020 through the beginning of the V28 phase-in. V28 was finalized in the CMS risk adjustment program and introduced via the 2024 Rate Announcement.

The reason CMS updated the model is clinical accuracy. V24 was built on diagnosis patterns from the 2010s, and HCC research published by the HHS Office of Inspector General identified a handful of categories that were producing RAF inflation disproportionate to clinical severity, including low-specificity depression diagnoses and mild atherosclerosis codes. V28 tightened those categories.

Structurally, V28 also rebuilt the HCC hierarchy rules that decide which category wins when two codes could both map. In V24 a patient with both uncomplicated diabetes (E11.9) and diabetes with CKD (E11.22) would roll up to a single "diabetes with complications" HCC, and the uncomplicated code was effectively ignored for RAF. V28 kept that rollup but reorganized complications into finer categories, so the specific assessment statement in the chart matters for a different reason than it did under V24. Under V24, coding E11.9 instead of the supported E11.22 cost diabetes RAF directly, V24 HCC 19 (0.105) paid less than HCC 18 (0.302). Under V28 the three diabetes tiers (HCC 36, 37, and 38) all carry the same 0.166 base weight, so coding E11.9 when E11.22 is supported does not lower the diabetes category itself, it forfeits the separate manifestation HCC (the CKD category) the specific code lets you link and capture on top. The coder-facing implication is the same, chart review effort shifts from "find-the-diagnosis" to "upgrade-the-specificity," but under V28 the dollars sit in the linked manifestation, not the diabetes tier.

CMS's own rationale for V28, stated in the 2024 Advance Notice and carried through the 2025 Rate Announcement, was that V24's category set had drifted from the clinical profile of the 2020s Medicare Advantage population. New drug therapies for diabetes, the shift in mental health diagnostic coding after DSM-5-TR, and the aging of the MA-enrolled population changed which conditions drive care utilization and which do not. V28 calibrated against those newer patterns. The CMS risk adjustment data repository publishes the full model software ZIP and the underlying coefficient tables for anyone who wants to audit the math directly.

Coders looking for a plain-English walkthrough of the category-by-category changes can read the V28 full implementation guide or the more condensed "what changed" summary. For a historical model-by-model comparison, the V24 vs V28 deep-dive is the most-cited reference in the HCC Buddy library.

The V24/V28 blend schedule (2024 to 2027)

CMS introduced V28 as a three-year blend to smooth revenue impact on MA plans. Each payment year's RAF score is computed twice (once under V24, once under V28) and the results are weighted:

Payment yearV24 weightV28 weightStatus
202467%33%Historical
202533%67%Historical
20260%100%Current
2027+0%100%Projected

Coders auditing claims for a specific payment year should apply the weighted model in effect for that year. The RAF score calculator can toggle between V24 and V28 for the same diagnosis list, which is the fastest way to see how a mixed panel shifts between payment years. The V28 transition guide walks through the practical implications of the 2026 switch for coding ops managers.

Category families that gained or lost ground

Gained specificity or finer categories in V28

  • Diabetes with chronic complications (E11.22, E11.40, E11.51)
  • Heart failure with reduced ejection fraction
  • Chronic kidney disease stages 4 and 5
  • Active substance use disorders
  • Major depressive disorder, severe

Lost HCC weight (RAF-negative)

  • Intermittent claudication without ischemia
  • Angina pectoris without CAD
  • Mild/unspecified depression (formerly HCC 59)
  • Substance use in remission
  • Protein-calorie malnutrition, unspecified

Coders reviewing charts for patients with the "lost weight" profile should reset expectations, extra documentation on those diagnoses no longer produces revenue. Chart review effort should shift toward the "gained specificity" list, where a single assessment statement can upgrade an unspecified code to a specified one and materially affect the 2026 RAF.

The 2026 HCC list, chronic conditions by category

The 2026 V28 payment HCC list is organized by clinical body system. The categories below are the highest-frequency HCCs across the Medicare Advantage population, the ones most MA plans see on 60%+ of risk-adjustable enrollees. A full category-to-category mapping against specific ICD-10 codes lives on the ICD-10 to HCC mapping hub, and every individual code can be looked up via the HCC Buddy encoder.

Endocrine (HCC 36 to 38)

Diabetes with and without complications. V28 split the former single diabetes HCC into three tiers. See the diabetes HCC coding guide for the full complication hierarchy.

Cardiovascular (HCC 221 to 238)

Heart failure (with and without reduced EF), acute and chronic ischemic heart disease, specified arrhythmias. Start with the heart failure HCC guide and the atrial fibrillation guide.

Renal (HCC 326 to 329)

CKD stages 3 to 5, ESRD, dialysis status. See the CKD HCC coding guide.

Respiratory (HCC 278 to 283)

COPD, asthma with specified severity, interstitial lung disease. See the COPD HCC coding guide.

Mental & Behavioral (HCC 151 to 155)

Major depressive disorder (severe), schizophrenia, bipolar disorder. Active substance use disorders sit in their own block (HCC 135 to 139). See the depression HCC coding guide.

Neurological (HCC 125 to 127, 198 to 199)

Alzheimer's, vascular dementia, Parkinson's, multiple sclerosis. See the dementia HCC coding guide.

Metabolic/Obesity (HCC 48)

Morbid obesity (BMI ≥ 40). See the obesity / BMI HCC coding guide.

The top 10 HCC codes across the MA population and the top 10 miscoded HCCs reports are the quickest way to prioritize chart review capacity for 2026. Both lists are HCC Buddy-maintained and updated against the current V28 coefficient set.

Browse the V28 categories

The highest-volume 2026 V28 payment categories by payable ICD-10-CM code count, grouped by clinical family. Each links to that category's reference page with its RAF segment factors, V28 hierarchy, and full member-code list.

Diabetes & endocrine

Cardiovascular & heart failure

Kidney disease (CKD)

Respiratory (COPD & lung)

Mental & behavioral health

Neurological & dementia

Cancer & neoplasms

Showing 37 high-frequency V28 categories across the most-coded clinical families. The number is each category's payable ICD-10-CM code count. View all 115 CMS-HCC V28 categories.

ICD-10-CM code shortcuts

Open these billable V28-mapped code pages directly. The category and chapter directories cover the full mapped set.

How the 2026 coefficient set changes RAF math

V28 RAF is still the sum of demographic factors plus HCC coefficients plus interaction terms, but the coefficients themselves moved. A community-dwelling non-dual 70-year-old female with diabetes with CKD (E11.22) carried a ~0.302 diabetes RAF under V24 but only 0.166 under V28, the diabetes coefficient itself came down. The same patient's peripheral vascular disease code (I73.9) that carried ~0.288 under V24 now carries 0.000, because I73.9 no longer maps to any HCC. Average contract-level RAF is down ~3.2% before any chart-review optimization.

Coders preparing payment-year 2026 projections should run the RAF calculator on representative panels side-by-side under V24 and V28 to identify which patients slipped below the capitation break-even line. The RAF score calculation guide walks through the demographic-plus-condition arithmetic that drives the final payment.

The ICD-10 combination codes RAF guide covers the specific code-pair rules, certain diagnoses combine to a higher-specificity HCC rather than stacking, and is the most common source of missed RAF lift during chart review.

MEAT documentation under V28

V28 did not change the MEAT documentation standard, every HCC submitted still requires Monitor, Evaluate, Assess, or Treat evidence in a face-to-face encounter during the payment year. What V28 changed is which conditions are worth the documentation effort. Provider education decks that previously emphasized vascular disease and mild depression should be reweighted toward diabetes specificity, heart failure severity, and CKD stage. See the MEAT criteria hub for the framework, the provider query templates for AHIMA-compliant prompts, and the RADV audit prep guide for how V28 documentation stands up under audit.

The parallel 2023 RADV final rule removed the fee-for-service adjuster and allowed CMS to extrapolate audit findings across contracts, which means unsupported V28 HCCs now produce larger payment recoveries than unsupported V24 HCCs would have under the prior rule. Compliance teams treating V28 as "just a coefficient change" are misreading the risk.

Practically, the MEAT bar under V28 is higher for the conditions that still pay. A diabetes encounter that previously cleared audit with "DM, on metformin, stable" now needs to name the complication (neuropathy, CKD stage, retinopathy) to land on a V28-mapped code like E11.22 , and the MEAT narrative has to support that specificity. Heart-failure notes that said "CHF, continue Lasix" need to document systolic vs diastolic, acute vs chronic, and the clinical monitoring that justified the encounter. Coders who learned V24-era shortcuts, accepting a "history of" phrase as MEAT, or letting ambiguous laterality ride, will see those charts flagged on the first RADV pull under the 2023 rule. Retraining the chart-review rubric is not optional; it is the difference between keeping and refunding V28 dollars.

The shift also changes what provider-education sessions should emphasize. Under V24, "code to the highest specificity" worked as a generic mantra because almost every chronic condition carried some RAF weight. Under V28, the three diabetes tiers (HCC 36, 37, and 38) all carry the same 0.166 base weight, so moving E11.9 to E11.22 does not, by itself, lift the diabetes coefficient. What specificity unlocks is the separate manifestation HCC: documenting the CKD behind E11.22 lets you also capture the kidney-disease category on top of diabetes, and documenting a foot ulcer (E11.621) captures HCC 383 in its own right. The uncomplicated code is not unmapped; the RAF lift comes from the additional mapped condition the specificity lets you code, not from a higher diabetes tier. Education content should lead with the map, not with the alphabet, and coder-QA dashboards should surface under-specified diabetes and heart-failure encounters as rework candidates, not as pass-through clean claims. Teams that rebuild their provider-facing cheat sheets to the V28 hierarchy code to the categories V28 actually pays; decks still written to V24 categories can steer coders toward HCCs that no longer map under V28, under-capturing where the model now rewards specificity. The same logic applies to retrospective chart review: V24-trained reviewers will flag dozens of "missed" HCCs per chart that no longer map, burning reviewer hours on zero-yield rework. Re-scoping the review queue to V28-mapped categories is a one-time project that pays back in the first quarter.

What coders should actually do for 100% V28

  • Re-audit the current-year problem list against the V28 map. Every patient's active problem list should be walked against the ICD-10 → HCC mapping tool to identify conditions that lost RAF weight (stop chasing) versus gained specificity (escalate to the provider).
  • Download the updated cheat sheet. The HCC Buddy cheat sheet now leads with the V28 decision tree rather than V24. Print one per workstation.
  • Install the Chrome extension. The HCC Buddy extension surfaces V28 HCC categories and RAF weights inline inside the EHR, so coders do not have to switch tabs during chart review.
  • Re-train providers on the new priority conditions. Use the payer guidelines library to pull your payer's specific V28 documentation guidance (CMS and major Medicare Advantage plans published provider-facing V28 briefs in 2024 and 2025).

Frequently Asked Questions

Related coding tools

ICD-10-CM Encoder

Look up any code and see V28 HCC + RAF inline.

ICD-10 to HCC crosswalk

Free V28 mapping lookup for one diagnosis code at a time.

Free RAF score calculator

Model PY2026 V28 scores with demographics and HCCs.

MEAT criteria

The documentation standard behind every V28 HCC.

Payer Guidelines Library

Search CMS and payer V28 documentation.

HCC coding cheat sheet

Free V28 decision tree PDF.

Built for HCC coders. Sourced from CMS, OIG, and the Federal Register.

Coder-first workflow · 2026 CMS V28 current · Reviewed against the April 2025 CMS Rate Announcement