HCC 213: Cardio-Respiratory Failure and Shock ICD-10-CM
CMS-HCC Category 213 (Cardio-Respiratory Failure and Shock) is a payment HCC in the V28 Medicare Advantage risk adjustment model. For payment year 2026 it adds a risk adjustment factor between 0.258 and 0.662 to a beneficiary's RAF score depending on the payment segment (0.370 for a community, non-dual, aged enrollee). 36 ICD-10-CM diagnosis codes map to HCC 213. A more severe related category (HCC 211 and HCC 212) supersedes it when both are reported.
RAF Weight by Payment Segment 7 segments
| Payment Segment | Relative Factor |
|---|---|
| Community, non-dual, aged | 0.370 |
| Community, partial-benefit dual, aged | 0.409 |
| Community, full-benefit dual, aged | 0.573 |
| Community, non-dual, disabled | 0.510 |
| Community, partial-benefit dual, disabled | 0.493 |
| Community, full-benefit dual, disabled | 0.662 |
| Institutional | 0.258 |
A beneficiary is scored in exactly one segment, set by Medicaid (dual) status, aged or disabled entitlement, and residence. Factors are relative weights, not dollar amounts; new-enrollee segments score on demographics only. In the hierarchy, HCC 211 (Respirator Dependence/Tracheostomy Status/Complications) and HCC 212 (Respiratory Arrest) supersede HCC 213 when reported together.
ICD-10-CM Codes That Map to HCC 213 36 codes
- I46.2 Cardiac arrest due to underlying cardiac condition from V24 HCC 84
- I46.8 Cardiac arrest due to other underlying condition from V24 HCC 84
- I46.9 Cardiac arrest, cause unspecified from V24 HCC 84
- I49.01 Ventricular fibrillation from V24 HCC 84
- I49.02 Ventricular flutter from V24 HCC 84
- J80 Acute respiratory distress syndrome from V24 HCC 84
- J81.0 Acute pulmonary edema from V24 HCC 84
- J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia from V24 HCC 84
- J96.01 Acute respiratory failure with hypoxia from V24 HCC 84
- J96.02 Acute respiratory failure with hypercapnia from V24 HCC 84
- J96.10 Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia from V24 HCC 84
- J96.11 Chronic respiratory failure with hypoxia from V24 HCC 84
- J96.12 Chronic respiratory failure with hypercapnia from V24 HCC 84
- J96.20 Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia from V24 HCC 84
- J96.21 Acute and chronic respiratory failure with hypoxia from V24 HCC 84
- J96.22 Acute and chronic respiratory failure with hypercapnia from V24 HCC 84
- J96.90 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia from V24 HCC 84
- J96.91 Respiratory failure, unspecified with hypoxia from V24 HCC 84
- J96.92 Respiratory failure, unspecified with hypercapnia from V24 HCC 84
- P22.0 Respiratory distress syndrome of newborn new to V28
- P26.0 Tracheobronchial hemorrhage originating in the perinatal period new to V28
- P26.1 Massive pulmonary hemorrhage originating in the perinatal period new to V28
- P26.8 Other pulmonary hemorrhages originating in the perinatal period new to V28
- P26.9 Unspecified pulmonary hemorrhage originating in the perinatal period new to V28
- P27.0 Wilson-Mikity syndrome new to V28
- P27.1 Bronchopulmonary dysplasia originating in the perinatal period new to V28
- P27.8 Other chronic respiratory diseases originating in the perinatal period new to V28
- P27.9 Unspecified chronic respiratory disease originating in the perinatal period new to V28
- P28.0 Primary atelectasis of newborn new to V28
- P28.10 Unspecified atelectasis of newborn new to V28
- P28.11 Resorption atelectasis without respiratory distress syndrome new to V28
- P28.19 Other atelectasis of newborn new to V28
- P28.5 Respiratory failure of newborn new to V28
- P29.81 Cardiac arrest of newborn new to V28
- R57.0 Cardiogenic shock from V24 HCC 84
- R57.9 Shock, unspecified from V24 HCC 84
Every code above carries the full HCC 213 weight when documented and reported on a Medicare Advantage encounter. The code link opens its full page with the complete risk adjustment card.
Questions About HCC 213
What is HCC 213 in the CMS-HCC model?
HCC 213 is CMS-HCC Category 213 (Cardio-Respiratory Failure and Shock) in the V28 risk adjustment model. It covers 36 ICD-10-CM diagnosis codes that raise a Medicare Advantage beneficiary's risk score when documented.
What is the RAF weight for HCC 213?
For payment year 2026, HCC 213 adds 0.370 to the RAF score of a community, non-dual, aged beneficiary (living at home, age 65 or over, not also enrolled in Medicaid). The published weights range from 0.258 to 0.662 across the seven payment segments shown above.
Which categories supersede HCC 213?
HCC 211 (Respirator Dependence/Tracheostomy Status/Complications) and HCC 212 (Respiratory Arrest) sit above HCC 213 in the hierarchy: when a beneficiary has diagnoses in both, only the more severe category is paid.
Related References
Source: Centers for Medicare & Medicaid Services, Payment Year 2026 risk adjustment mapping and model software releases (CMS-HCC V28), applied to the FY 2026 ICD-10-CM code set. ICD List is not affiliated with CMS.
