HCC 226: Heart Failure, Except End Stage and Acute ICD-10-CM
CMS-HCC Category 226 (Heart Failure, Except End Stage and Acute) is a payment HCC in the V28 Medicare Advantage risk adjustment model. For payment year 2026 it adds a risk adjustment factor between 0.217 and 0.537 to a beneficiary's RAF score depending on the payment segment (0.360 for a community, non-dual, aged enrollee). 34 ICD-10-CM diagnosis codes map to HCC 226. A more severe related category (HCC 221, HCC 222, HCC 223, HCC 224, and HCC 225) supersedes it when both are reported.
RAF Weight by Payment Segment 7 segments
| Payment Segment | Relative Factor |
|---|---|
| Community, non-dual, aged | 0.360 |
| Community, partial-benefit dual, aged | 0.311 |
| Community, full-benefit dual, aged | 0.406 |
| Community, non-dual, disabled | 0.442 |
| Community, partial-benefit dual, disabled | 0.411 |
| Community, full-benefit dual, disabled | 0.537 |
| Institutional | 0.217 |
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 221 (Heart Transplant Status/Complications), HCC 222 (End Stage Heart Failure), HCC 223 (Heart Assist Device/Artificial Heart), HCC 224 (Acute on Chronic Heart Failure), and HCC 225 (Acute Heart Failure (Excludes Acute on Chronic)) supersede HCC 226 when reported together. HCC 226 in turn supersedes HCC 227 (Cardiomyopathy/Myocarditis).
ICD-10-CM Codes That Map to HCC 226 34 codes
- I09.81 Rheumatic heart failure from V24 HCC 85
- I11.0 Hypertensive heart disease with heart failure from V24 HCC 85
- I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease from V24 HCC 85
- I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease from V24 HCC 85, HCC 136
- I27.0 Primary pulmonary hypertension from V24 HCC 85
- I27.1 Kyphoscoliotic heart disease from V24 HCC 85
- I27.20 Pulmonary hypertension, unspecified from V24 HCC 85
- I27.21 Secondary pulmonary arterial hypertension from V24 HCC 85
- I27.22 Pulmonary hypertension due to left heart disease from V24 HCC 85
- I27.23 Pulmonary hypertension due to lung diseases and hypoxia from V24 HCC 85
- I27.24 Chronic thromboembolic pulmonary hypertension from V24 HCC 85
- I27.29 Other secondary pulmonary hypertension from V24 HCC 85
- I27.81 Cor pulmonale (chronic) from V24 HCC 85
- I27.83 Eisenmenger's syndrome from V24 HCC 85
- I27.89 Other specified pulmonary heart diseases from V24 HCC 85
- I27.9 Pulmonary heart disease, unspecified from V24 HCC 85
- I28.0 Arteriovenous fistula of pulmonary vessels from V24 HCC 85
- I28.1 Aneurysm of pulmonary artery from V24 HCC 85
- I28.8 Other diseases of pulmonary vessels from V24 HCC 85
- I28.9 Disease of pulmonary vessels, unspecified from V24 HCC 85
- I50.1 Left ventricular failure, unspecified from V24 HCC 85
- I50.20 Unspecified systolic (congestive) heart failure from V24 HCC 85
- I50.22 Chronic systolic (congestive) heart failure from V24 HCC 85
- I50.30 Unspecified diastolic (congestive) heart failure from V24 HCC 85
- I50.32 Chronic diastolic (congestive) heart failure from V24 HCC 85
- I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure from V24 HCC 85
- I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure from V24 HCC 85
- I50.810 Right heart failure, unspecified from V24 HCC 85
- I50.812 Chronic right heart failure from V24 HCC 85
- I50.814 Right heart failure due to left heart failure from V24 HCC 85
- I50.82 Biventricular heart failure from V24 HCC 85
- I50.83 High output heart failure from V24 HCC 85
- I50.89 Other heart failure from V24 HCC 85
- I50.9 Heart failure, unspecified from V24 HCC 85
Every code above carries the full HCC 226 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 226
What is HCC 226 in the CMS-HCC model?
HCC 226 is CMS-HCC Category 226 (Heart Failure, Except End Stage and Acute) in the V28 risk adjustment model. It covers 34 ICD-10-CM diagnosis codes that raise a Medicare Advantage beneficiary's risk score when documented.
What is the RAF weight for HCC 226?
For payment year 2026, HCC 226 adds 0.360 to the RAF score of a community, non-dual, aged beneficiary. The published weights range from 0.217 to 0.537 across the seven payment segments shown above.
Which categories supersede HCC 226?
HCC 221 (Heart Transplant Status/Complications), HCC 222 (End Stage Heart Failure), HCC 223 (Heart Assist Device/Artificial Heart), HCC 224 (Acute on Chronic Heart Failure), and HCC 225 (Acute Heart Failure (Excludes Acute on Chronic)) sit above HCC 226 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.
