HCC Risk Score Calculator
Turn a diagnosis list into a V28 risk score. This calculator runs the official CMS-HCC model — mapping, hierarchies, interactions and all — for the community, non-dual, aged segment.
In Medicare Advantage, the diagnosis codes on a patient's claims become a risk score — and the risk score becomes payment. The CMS-HCC model sorts thousands of ICD-10-CM codes into payment categories (HCCs), applies hierarchies so related conditions are not double-counted, and weights each category with a published coefficient. This calculator runs the official CMS-HCC Version 28 model — the 2026 model software, community / non-dual / aged segment — on any diagnosis list, right in your browser.
Estimate a V28 risk score (RAF)
How the model works
- Mapping. Each diagnosis maps to a condition category using the CMS V28 diagnosis-to-CC table in the official model software. Under V28, roughly 8,000 ICD-10-CM codes map to one of 115 payment HCCs — many familiar codes (including uncomplicated hypertension, I10) map to nothing at all.
- Hierarchies. When a patient has several categories in the same disease family, only the most severe counts: metastatic cancer (HCC17) zeroes out the other cancer categories, and diabetes with chronic complications outranks uncomplicated diabetes. This tool applies the hierarchies in the same order as the CMS software, including its special rule for isolated HCC223.
- Interactions and counts. Certain combinations pay more together than apart (for example diabetes with heart failure), and the model adds a further amount when a patient has 5 or more payment HCCs. Both are included here, exactly as published for the community, non-dual, aged segment.
- The demographic base. Age and sex set the starting score — from 0.330 for a woman aged 65–69 up to 0.896 for a man aged 95+. Diagnoses add on top of it.
What this estimate leaves out
This is the V28 model only, for the default community / non-dual / aged segment, scored the way the CMS model software scores it. Real Medicare Advantage payment also applies the model's other segments (dual-eligible, institutional, new enrollee), diagnosis age/sex validity edits, the statutory coding-intensity adjustment and CMS's normalisation factor, and blends model versions during phase-in years. Use this tool to understand and sanity-check scores — not as a payment guarantee. Data: CMS 2026 CMS-HCC model software V2826.115.T1 (midyear/final release) — ICD-10-to-CC mapping, hierarchies and CNA coefficients.
Pair this with the ICD-10 Specificity Checker to confirm each code is billable before you rely on it.
Disclaimer: This tool is for educational and estimation purposes only and does not constitute billing, coding or medical advice. Coverage, coding and payment rules vary by payer and change over time — always verify with the current CMS files and the payer's own policy before submitting claims or making financial decisions.
Frequently asked questions
What is a RAF score?
The Risk Adjustment Factor is the number Medicare Advantage payment is built on: a beneficiary with a RAF of 1.000 is expected to cost the average amount, 2.000 roughly twice the average. It combines a demographic base (age, sex, entitlement) with weighted diagnosis categories (HCCs) from the CMS-HCC model — Version 28 for the 2026 model year.
Why did my diagnosis code produce no HCC?
Under V28 only about 8,000 of the ~74,000 billable ICD-10-CM codes map to a payment HCC. CMS narrowed the model to diagnoses that predict cost in the Medicare Advantage population — common examples that no longer map include uncomplicated hypertension (I10). A code can also be mapped but then removed by a hierarchy when a more severe related category is present.
Which model segment does this calculator use?
The community, non-dual, aged segment (CNA) — the default segment for a Medicare Advantage member aged 65+ who is not dually eligible and not institutionalised. Coefficients differ for dual-eligible, disabled and institutional segments, so scores for those members will differ from this estimate.