CMS-HCC Risk Adjustment

Model (V24)

ICD-10-CM to CMS-HCC Crosswalk

CMS-HCC Model Disease hierarchy
On April 1, 2019, the Centers for Medicare & Medicaid The CMS-HCC Model incorporates disease hierarchies in
Services (CMS) announced an updated hierarchical which payment will only be associated with the most severe
condition category (HCC) risk adjustment model. The manifestation of a disease. If another HCC in the hierarchy is
following HCCs were added to the 2020 Alternative reported in the same calendar year, then the lower severity
Payment Condition Count (APCC) Model: dementia HCC will be dropped. For example:
with complications (HCC 51); dementia without ■ If HCC 18 (diabetes with chronic complication) is
complication (HCC 52); and pressure ulcer of skin with reported, then HCC 19 (diabetes without complication)
partial thickness skin loss (HCC 159). will be dropped if both are reported in the same
calendar year.
There are more than 9,700 ICD-10-CM codes that map ■ Only HCC 18 will be used in calculating the Medicare
to one or more of the 86 HCC codes included in the Advantage member’s risk score.
2020 CMS-HCC Risk Adjustment Model (Version 24).
A code can map to more than one HCC as ICD-10-CM The table below contains a crosswalk of the ICD-10-CM
contains combination codes (i.e., one code can codes that are included in the 2020 CMS-HCC Model (V24).
represent two diagnoses or a diagnosis with a The HCC(s) that will be dropped is identified in the disease
complication). This model will be used in calculating a hierarchy column. The table includes the HCC category
Medicare Advantage (MA) member’s blended descriptions along with the HCC code and associated
risk score. disease hierarchy.

* Note: The CMS-HCC (V24) model and mappings in the table are
subject to change with updates to the ICD-10-CM code set on
More than 9,700 ICD-10-CM codes October 1, 2020.
map to one or more 86 HCCs

https://providers.amerigroup.com
 Disease
ICD-10-CM codes HCC category description HCC hierarchy
B20, B97.35, Z21 HIV/AIDS 1
A02.1, A20.7, A22.7, A26.7, A32.7, A39.2-A39.4, A40.-, A41.-, A42.7, A48.3, A54.86, B00.7, B37.7, Septicemia, sepsis and 2
P36.-, R57.1, R57.8, R65.1-, R65.2-, T81.12XA systemic inflammatory
response syndrome/shock
A07.2, A31.0, A31.2, B25.-, B37.1, B37.7, B37.81, B44.0-B44.7, B44.89, B44.9, B45.-, B46.-, B48.4, Opportunistic infections 6
B48.8, B58.2, B58.3, B59
C77.0-C77.2, C77.4-C77.8, C78.-, C79.00-C79.72, C79.89, C79.9, C7B.-, C80.0, C91.0-, Metastatic cancer and acute 8 9, 10, 11, 12
C92.00-C92.02, C92.40-C92.A2, C93.0-, C94.00-C94.22, C94.40-C94.42, C95.0- leukemia
C15.-, C16.-, C17.-, C22. -, C23, C24.-, C25.-, C33, C34.-, C38.4, C45.-, C48.-, C90.00-C90.22, Lung and other severe 9 10, 11, 12
C92.10-C92.32, C92.9-, C92.Z-, C93.10-C93.92, C93.Z-, C94.30-C94.32, C94.80-C94.82 cancers
C40.-, C41.-, C46.-, C47.-, C49.-, C56.-, C57.00-C57.4, C58, C70.-, C71.-, C72.-, C74.-, C75.1-C75.3, Lymphoma and other cancers 10 11, 12
C77.3, C77.9, C79.2, C79.81, C79.82, C81.-, C82.-, C83.-, C84.-, C85.-, C86.-, C88.2-C88.9, C90.3-,
C91.-, C95.10-C95.92, C96.-
C01, C02.-, C03.-, C04.-, C05.-, C06.-, C07, C08.-, C09.-, C10.-, C11.-, C12, C13.-, C14.-, C18.-, C19, Colorectal, bladder and other 11 12
C20, C21.-, C26.-, C30.-, C31.-, C32.-, C37, C38.0-C38.3, C38.8, C39.-, C51.-, C52, C53.-, cancers
C57.7-C57.9, C64.-, C65.-, C66.-, C67.-, C68.-
C43.-, C4A.-, C50.-, C54.-, C55, C60.-, C61, C62.-, C63.-, C69.-, C73, C75.0, C75.4-C75.9, C76.-, Breast, prostate, and other 12
C7A.-, C80.1, C80.2, D03.-, D18.02, D32.-, D33.-, D35.2-D35.4, D42.-, D43.-, D44.3-D44.7, D49.6, cancers and tumors
E34.0, Q85.-
E08.0-, E08.1-, E08.641, E09.0-, E09.1-, E09.641, E10.1-, E10.641, E11.0-, E11.1- , E11.641, E13.0-, Diabetes with acute 17 18, 19
E13.1-, E13.641 complications
E08.21-E08.638, E08.649-E08.8, E09.21-E09.638, E09.649-E09.8, E10.21-E10.638, E10.649-E10.8, Diabetes with chronic 18 19
E11.21-E11.638, E11.649-E11.8, E13.21-E13.638, E13.649-E13.8 complications
E08.9, E09.9, E10.9, E11.9, E13.9, Z79.4 Diabetes without 19
complication
E40, E41, E42, E43, E44.0, E44.1, E45, E46, E64.0, R64 Protein-calorie malnutrition 21
E66.01, E66.2, Z68.41, Z68.42, Z68.43, Z68.44, Z68.45 Morbid obesity 22
A39.1, C88.0, D84.1, D89.1, E03.5, E15, E20.0, E20.8, E20.9, E21.-, E22.-, E23.-, E24.-, E25.-, E26.-, Other significant endocrine 23
E27.-, E31.-, E32.-, E34.4, E70.-, E71.-, E72.-, E74.00-E74.09, E74.20-E74.29, E74.4-E74.9, E75.21, and metabolic disorders
E75.22, E75.240-E75.249, E75.3, E76.-, E77.-, E79.1-E79.9, E80.0-E80.3, E83.110, E85.-, E88.01,
E88.4-, E88.89, E89.2, E89.3, E89.6, H49.811-H49.819, N25.1, N25.81
I85.-, K70.41, K71.11, K72.01-K72.91, K76.6, K76.7, K76.81 End-stage liver disease 27 28, 29, 80
K70.30-K70.9, K74.3-K74.69 Cirrhosis of liver 28 29
B18.-, K73.-, K75.4 Chronic hepatitis 29
A54.85, K25.1, K25.2, K25.5, K25.6, K26.1, K26.2, K26.5, K26.6, K27.1, K27.2, K27.5, K27.6, K28.1, Intestinal obstruction/ 33
K28.2, K28.5, K28.6, K50.012, K50.112, K50.812, K50.912, K51.012, K51.212, K51.312, K51.412, perforation
K51.512, K51.812, K51.912, K56.-, K59.31, K63.1, K65.-, K67, K68.12, K68.19
K86.0, K86.1 Chronic pancreatitis 34
K50.-, K51.- Inflammatory bowel disease 35
A01.04, A01.05, A02.23, A02.24, A39.83, A39.84, A50.55, A54.4-, A66.6, A69.23, B06.82, B26.85, Bone/joint/muscle 39
B42.82, M00.-, M01.-, M02.1-, M02.8-, M02.9, M46.2-, M46.3-, M72.6, M86.-, M87.-, M89.6-, infections/necrosis
M90.5-
L40.5-, M02.3-, M04.-, M05.-, M06.-, M08.-, M12.0-, M30.-, M31.0-M31.7, M32.-, M33.-, M34.-, Rheumatoid arthritis and 40
M35.00-M35.3, M35.5, M35.8, M35.9, M36.0, M36.8, M45.-, M46.00-M46.1, M46.50-M46.99, inflammatory connective
M48.8X-, M49.8- tissue disease
D46.-, D46.A, D46.B, D46.C, D46.Z, D47.4, D57.0-, D57.1, D57.2-, D57.4-, D57.8-, D59.-, D60.-, Severe hematological 46 48
D61.0-, D61.1, D61.2, D61.3, D61.82, D61.9, D66, D67, D75.81 disorders
D61.8-, D70.-, D71, D72.0, D76.-, D80.-, D81.1-D81.7, D81.89, D81.9, D82.-, D83.-, D84.0, D84.8, Disorders of immunity 47
D84.9, D89.3, D89.8-, D89.9
 Disease
ICD-10-CM codes HCC category description HCC hierarchy
C94.6, D45, D47.1, D47.3, D47.9, D47.Z-, D55.-, D56.0-D56.2, D56.4-D56.8, D57.3, D58.-, Coagulation defects and 48
D64.0-D64.3, D65, D68.-, D69.0-D69.49, D69.6-D69.9, D75.82 other specified hematological
disorders
F01.51, F02.81, F03.91, G91.- Dementia with complications 51 52
A81.- , E75.00, E75.01, E75.02, E75.09, E75.10, E75.11, E75.19, E75.23, E75.25, E75.26, E75.29, Dementia without 52
E75.4, F01.50, F02.80, F03.90, F04, G13.2, G13.8, G30.-, G31.01, G31.09, G31.1, G31.2, G31.81, complication
G31.82, G31.83, G31.85, G31.89, G31.9, G93.7, I67.3
F10.150-F10.159, F10.231, F10.232, F10.250-F10.259, F10.26, F10.27, F10.950-F10.97, F11.15-, Substance use with psychotic 54 55, 56
F11.25- , F11.95-, F12.15-, F12.25-, F12.95-, F13.15-, F13.231, F13.232, F13.250- F13.27, F13.931, complications
F13.932, F13.950-F13.97, F14.15-, F14.25-, F14.95-, F15.15-, F15.25-, F15.95-, F16.15-, F16.25-,
F16.95-, F18.17, F18.25-, F18.27, F18.95-, F18.97, F19.15-, F19.16, F19.17, F19.231, F19.232, F19.25-,
F19.26, F19.27, F19.931, F19.932, F19.950-F19.97
F10.120-F10.129, F10.14, F10.18-, F10.19, F10.20, F10.21, F10.22-, F10.230, F10.239, F10.24, Substance use disorder, 55 56
F10.28-, F10.29, F10.92-, F10.94, F10.98-, F10.99, F11.12-, F11.14, F11.18-, F11.19, F11.20, F11.21, moderate/severe or
F11.22-, F11.23, F11.24, F11.28-, F11.29, F11.92-, F11.93, F11.94, F11.98-, F11.99, F12.12-, substance use with
F12.18-, F12.19, F12.20, F12.21, F12.22-, F12.28-, F12.29, F12.92-, F12.98-, F12.99, F13.12, complications
F13.14, F13.18-, F13.19, F13.20, F13.21, F13.22-, F13.230, F13.239, F13.24, F13.28-, F13.29,
F13.92-, F13.930, F13.939, F13.94, F13.98-, F13.99, F14.12-, F14.14, F14.18-, F14.19, F14.20,
F14.21, F14.22-, F14.23, F14.24, F14.28-, F14.29, F14.92-, F14.94, F14.98-, F14.99, F15.12-, F15.14,
F15.18-, F15.19, F15.20, F15.21, F15.22-, F15.23, F15.24, F15.28-, F15.29, F15.92-, F15.93, F15.94,
F15.98-, F15.99, F16.12-, F16.14, F16.18-, F16.19, F16.20, F16.21, F16.22-, F16.24, F16.28-, F16.29,
F16.92-, F16.94, F16.98-, F16.99, F18.12-, F18.14, F18.18, F18.19, F18.20, F18.21, F18.22-, F18.24,
F18.28-, F18.29, F18.92-, F18.94, F18.98-, F18.99, F19.120-F19.129, F19.14, F19.18-, F19.19,
F19.20, F19.21, F19.22-F19.230, F19.239, F19.24, F19.28-, F19.29, F19.92-, F19.930, F19.939,
F19.94, F19.98-, F19.9, T40.0X1A, T40.0X4A, T40.1X1A, T40.1X4A, T40.2X1A, T40.2X4A, T40.3X1A,
T40.3X4A, T40.4X1A, T40.4X4A, T40.5X1A, T40.5X4A, T40.601A, T40.604A, T40.691A, T40.694A,
T40.8X1A, T40.8X4A, T40.901A, T40.904A, T40.991A, T40.994A, T43.601A, T43.604A, T43.611A,
T43.614A, T43.621A, T43.624A, T43.631A, T43634A, T43.694A, T51.0X1A, T51.0X4A
F11.1-, F13.1-, F14.1-, F15.1-, F16.1-, F18.1-, F19.1- Substance use disorder, mild, 56
except alcohol and cannabis
F20.-, F25.- Schizophrenia 57 58, 59, 60
F23, F28, F29 Reactive and unspecified 58 59, 60
psychosis
F22, F24, F30.-, F31.-, F32.0-F32.8, F33.-, F34.-, F39, T14.91X(A)(D)(S), T36.0X2(A)(S), Major depressive, bipolar 59 60
T36.1X2(A)(S), T36.2X2(A)(S), T36.3X2(A)(S), T36.4X2(A)(S), T36.5X2(A)(S), T36.6X2(A)(S), and paranoid disorders
T36.7X2(A)(S), T36.8X2(A)(S), T36.9X2(A)(S), T37.0X2(A)(S), T37.1X2(A)(S), T37.2X2(A)(S),
T37.3X2(A)(S), T37.4X2(A)(S), T37.5X2(A)(S), T37.8X2(A)(S), T37.9X2(A)(S), T38.0X2(A)(S),
T38.1X2(A)(S), T38.2X2(A)(S), T38.3X2(A)(S), T38.4X2(A)(S), T38.5X2(A)(S), T38.6X2(A)(S),
T38.7X2(A)(S), T38.802(A)(S), T38.812(A)(S), T38.892(A)(S), T38.902(A)(S), T38.992(A)(S),
T39.012(A)(S), T39.092(A)(S), T39.1X2(A)(S), T39.2X2(A)(S), T39.312(A)(S), T39.392(A)(S),
T39.4X2(A)(S), T39.8X2(A)(S), T39.92X(A)(S), T40.0X2(A)(S), T40.1X2(A)(S), T40.2X2(A)(S),
T40.3X2(A)(S), T40.4X2(A)(S), T40.5X2(A)(S), T40.602 A)(S), T40.692 A)(S), T40.7X2(A)(S),
T40.8X2(A)(S), T40.902(A)(S), T40.992(A)(S), T41.0X2(A)(S), T41.1X2(A)(S), T41.202(A)(S),
T41.292(A)(S), T41.3X2(A)(S), T41.42X(A)(S), T41.5X2(A)(S), T42.0X2(A)(S), T42.1X2(A)(S),
T42.2X2(A)(S), T42.3X2(A)(S), T42.4X2(A)(S), T42.5X2(A)(S), T42.6X2(A)(S), T42.72(A)(S),
T42.8X2(A)(S), T43.012(A)(S), T43.022(A)(S), T43.1X2(A)(S), T43.202(A)(S), T43.212(A)(S),
T43.222(A)(S), T43.292(A)(S), T43.3X2(A)(S), T43.4X2(A)(S), T43.502(A)(S), T43.592(A)(S),
T43.602(A)(S), T43.612(A)(S), T43.622(A)(S), T43.632(A)(S), T43.692(A)(S), T43.8X2(A)(S),
T43.9X2(A)(S), T44.0X2(A)(S), T44.1X2(A)(S), T44.2X2(A)(S), T44.3X2(A)(S), T44.4X2(A)(S),
T44.5X2(A)(S), T44.6X2(A)(S), T44.7X2(A)(S), T44.8X2(A)(S), T44.902(A)(S), T44.992(A)(S),
T45.0X2(A)(S), T45.1X2(A)(S), T45.2X2(A)(S), T45.3X2(A)(S), T45.4X2(A)(S), T45.512(A)(S),
T45.522(A)(S), T45.602(A)(S), T45.612(A)(S), T45.622(A)(S), T45.692(A)(S), T45.7X2(A)(S),
T45.8X2(A)(S), T45.92X(A)(S), T46.0X2(A)(S), T46.1X2(A)(S), T46.2X2(A)(S), T46.3X2(A)(S),
T46.4X2(A)(S), T46.5X2(A)(S), T46.6X2(A)(S), T46.7X2(A)(S), T46.8x2(A)(S), T46.902(A)(S),
T46.992(A)(S), T47.0X2(A)(S), T47.1X2(A)(S), T47.2X2(A)(S), T47.3X2(A)(S), T47.4X2(A)(S),
T47.5X2(A)(S), T47.6X2(A)(S), T47.7X2(A)(S), T47.8X2(A)(S), T47.92X(A)(S), T48.0X2(A)(S),
T48.1X2(A)(S), T48.202(A)(S), T48.292(A)(S), T48.3X2(A)(S), T48.4X2(A)(S), T48.5X2(A)(S),
T48.6X2(A)(S), T48.902(A)(S), T48.992(A)(S), T49.0X2(A)(S), T49.1X2(A)(S), T49.2X2(A)(S),
T49.3X2(A)(S), T49.4X2(A)(S), T49.5X2(A)(S), T49.6X2(A)(S), T49.7X2(A)(S), T49.8X2(A)(S),
T49.92X(A)(S), T50.0X2(A)(S), T50.1X2(A)(S), T50.2X2(A)(S), T50.3X2(A)(S), T50.4X2(A)(S),
 Disease
ICD-10-CM codes HCC category description HCC hierarchy
T50.5X2(A)(S), T50.6X2(A)(S), T50.7X2(A)(S), T50.8X2(A)(S), T50.902(A)(S), T50.992(A)(S), Major depressive, bipolar and 59 60
T50.A12(A)(S), T50.A22(A)(S), T50.A92(A)(S), T50.B12(A)(S), T50.B92(A)(S), T50.Z12(A)(S), paranoid disorders (cont.)
T50.Z92(A)(S), T51.0X2(A)(S), T51.1X2(A)(S), T51.2X2(A)(S), T51.3X2(A)(S), T51.8X2(A)(S),
T51.92X(A)(S), T52.0X2(A)(S), T52.1X2(A)(S), T52.2X2(A)(S), T52.3X2(A)(S), T52.4X2(A)(S),
T52.8X2(A)(S), T52.92X(A)(S), T53.0X2(A)(S), T53.1X2(A)(S), T53.2X2(A)(S), T53.3X2(A)(S),
T53.4X2(A)(S), T53.5X2(A)(S), T53.6X2(A)(S), T53.7X2(A)(S), T53.92X(A)(S), T54.0X2(A)(S),
T54.1X2(A)(S), T54.2X2(A)(S), T54.3X2(A)(S), T54.92X(A)(S), T54.0X2(A)(S), T55.0X2(A)(S),
T55.1X2(A)(S), T56.0X2(A)(S), T56.1X2(A)(S), T56.2X2(A)(S), T56.3X2(A)(S), T56.4X2(A)(S),
T56.5X2(A)(S), T56.6X2(A)(S), T56.7X2(A)(S), T56.812(A)(S), T56.892(A)(S), T57.0X2(A)(S),
T57.1X2(A)(S), T57.2X2(A)(S), T57.3X2(A)(S), T57.8X2(A)(S), T57.92X(A)(S), T58.02X(A)(S),
T58.12X(A)(S), T58.2X2(A)(S), T58.8X2(A)(S), T58.92X(A)(S), T59.0X2(A)(S), T59.1X2(A)(S),
T59.2X2(A)(S), T59.3X2(A)(S), T59.4X2(A)(S), T59.5X2(A)(S), T59.6X2(A)(S), T59.7X2(A)(S),
T59.812(A)(S), T59.892(A)(S), T59.92X(A)(S), T60.0X2(A)(S), T60.1X2(A)(S), T60.2X2(A)(S),
T60.3X2(A)(S), T60.4X2(A)(S), T60.8X2(A)(S), T60.92X(A)(S), T61.02X(A)(S), T61.12X(A)(S),
T61.772(A)(S), T61.782(A)(S), T61.8X2(A)(S), T61.92X(A)(S), T62.0X2(A)(S), T62.1X2(A)(S),
T62.8X2(A)(S), T62.92X(A)(S), T63.002(A)(S), T63.012(A)(S), T63.022(A)(S), T63.032(A)(S),
T63.042(A)(S), T63.062(A)(S), T63.072(A)(S), T63.082(A)(S), T63.092(A)(S), T63.112(A)(S),
T63.122(A)(S), T63.192(A)(S), T63.2X2(A)(S), T63.302(A)(S), T63.312(A)(S), T63.322(A)(S),
T63.332(A)(S), T63.392(A)(S), T63.412(A)(S), T63.422(A)(S), T63.432(A)(S), T63.442(A)(S),
T63.452(A)(S), T63.462(A)(S), T63.482(A)(S), T63.512(A)(S), T63.592(A)(S), T63.612(A)(S),
T63.622(A)(S), T63.632(A)(S), T63.692(A)(S), T63.712(A)(S), T63.792(A)(S), T63.812(A)(S),
T63.822(A)(S), T63.832(A)(S), T63.892(A)(S), T63.92X(A)(S), T64.02X(A)(S), T64.82X(A)(S),
T65.0X2(A)(S), T65.1X2(A)(S), T65.212(A)(S), T65.222(A)(S), T65.292(A)(S), T65.3X2(A)(S),
T65.4X2(A)(S), T65.5X2(A)(S), T65.6X2(A)(S), T65.812(A)(S), T65.822(A)(S), T65.832(A)(S),
T65.892(A)(S), T65.92X(A)(S), T71.112(A)(S), T71.122(A)(S), T71.132(A)(S), T71.152(A)(S),
T71.162(A)(S), T71.192(A)(S), T71.222(A)(S), T71.232(A)(S), X71.-(A)(D)(S), X72.-(A)(D)(S),
X73.-(A)(D)(S), X74.-(A)(D)(S), X75.-(A)(D)(S), X76.-(A)(D)(S), X77.-(A)(D)(S), X78.-(A)(D)(S),
X79.-(A)(D)(S), X80.-(A)(D)(S), X81.-(A)(D)(S), X82.-(A)(D)(S), X83.-(A)(D)(S)
F21, F44.0, F44.1, F44.81, F48.1, F60.0-F60.9 Personality disorder 60
G82.5-, R53.2, S14.11-(A)(D)(S) Quadriplegia 70 71, 72, 103,
104, 169
G82.20-G82.22, S24.11-(A)(D)(S) Paraplegia 71 72, 104
B00.82, B01.12, B02.24, G04.1, G04.89, G04.91, G05.4, G11.-, G12.0, G12.1, G12.8, G12.9, G32.0, Spinal cord disorders/injuries 72 169
G32.81, G37.3, G37.4, G83.4, G90.1, G95.-, G99.2, Q00.-, Q01.-, Q02, Q03.-, Q04.-, Q05.-, Q06.-,
Q07.-, S14.0-(A)(D)(S), S14.10-(A)(D)(S), S14.12-(A)(D)(S), S14.13-(A)(D)(S), S14.14-(A)(D)(S),
S14.15-(A)(D)(S), S24.0-(A)(D)(S), S24.10-(A)(D)(S), S24.13-(A)(D)(S), S24.14-(A)(D)(S), S24.15-(A)(D)
(S), S34.0-(A)(D)(S), S34.1-(A)(D)(S), S34.3XX(A)
G12.2- Amyotrophic lateral sclerosis 73
and other motor neuron
disease
G80.- Cerebral palsy 74
D86.82, G13.0, G13.1, G61.-, G62.0-G62.82, G63, G65.-, G70.-, G73.1-G73.3, M05.5-, M34.83 Myasthenia gravis/myoneural 75
disorders and guillain-barre
syndrome/inflammatory and
toxic neuropathy
G71.0, G71.11, G71.2 Muscular dystrophy 76
G35, G36.-, G37.0, G37.1, G37.2, G37.5, G37.8, G37.9 Multiple sclerosis 77
G10, G20, G21.11, G21.19, G21.2-G21.9, G23.-, G90.3 Parkinson's and Huntington's 78
diseases
G40.01-, G40.10-, G40.20-, G40.21-, G40.30-, G40.31-, G40.40-, G40.41-, G40.50-, G40.80-, Seizure disorders and 79
G40.81-, G40.82-, G40.89, G40.90-, G40.91-, G40.A0-, G40.A1-, G40.B0-, G40.B1-, R56.- convulsions
G93.1, G93.5, G93.6, R40.20, R40.21-, R40.22-, R40.23-, R40.24-, R40.3 Coma, brain compression/ 80
anoxic damage
J95.0-, J95.850, J95.859, Z43.0, Z93.0, Z99.11, Z99.12 Respirator dependence/ 82 83, 84
tracheostomy status
R09.2 Respiratory arrest 83 84
 Disease
ICD-10-CM codes HCC category description HCC hierarchy
I46.-, I49.0-, J80, J81.0, J95.1-J95.3, J95.82-, J96.-, R57.0, R57.9, T81.11XA Cardio-respiratory failure 84
and shock
A36.81, B33.24, I09.81, I11.0, I13.0, I13.2, I26.0-, I27.0, I27.1, I27.2, I27.20, I27.21, I27.22, I27.23, Congestive heart failure 85
I27.24, I27.29, I27.81, I27.83, I27.89, I27.9, I28.-, I42.-, I43, I50.1-I50.9, I51.4, I51.5
I21.0-, I21.1-, I21.2-, I21.3, I21.4, I21.9, I21.A1, I21.A9, I22.-, I23.4, I23.5, I51.1, I51.2 Acute myocardial infarction 86 87, 88
I20.0, I23.0-I23.8, I24.-, I25.110, I25.700, I25.710, I25.720, I25.730, I25.750, I25.760, I25.790 Unstable angina and other 87 88
acute ischemic heart disease
I20.1-I20.9, I25.111, I25.118-I25.119, I25.701-I25.709, I25.711-I25.719, I25.721-I25.729, Angina pectoris 88
I25.731-I25.739, I25.751-I25.759, I25.761-I25.769, I25.791-I25.799
I44.2, I47.-, I48.-, I49.2, I49.5 Specified heart arrhythmias 96
I60.-, I61.-, I62.- Cerebral hemorrhage 99 100
I63.-, I97.81-, I97.82- Ischemic or unspecified 100
stroke
G81.-, I69.05-, I69.15-, I69.25-, I69.35-, I69.85-, I69.95- Hemiplegia/hemiparesis 103 104
G83.0-G83.3-, G83.5-G83.9, I69.03-, I69.04-, I69.06-, I69.13-, I69.14-, I69.16-, I69.23-, I69.24, Monoplegia, other paralytic 104
I69.26-, I69.33-, I69.34-, I69.36-, I69.83-, I69.84-, I69.86-, I69.93-, I69.94-, I69.96- syndromes
A48.0, E08.52, E09.52, E10.52, E11.52, E13.52, I70.231-I70.269, I70.331-I70.369, Atherosclerosis of extremity 106 107, 108,
I70.431-I70.469, I70.531-I70.569, I70.631-I70.669, I70.731-I70.769, I73.01, I96 with ulceration or gangrene 161, 189
I26.0-, I26.9-, I27.82, I67.0, I71.0-, I71.-, I74.-, I75.-, I76, I77.70-I77.79, I83.00-, I83.01-, Vascular disease with 107 108
I83.02-, I83.20-, I83.21-, I83.22-, I87.01-, I87.03-, I87.31-, I87.33-, K55.0-, K55.3-, N28.0 complications
E08.51, E08.52, E09.51, E09.52, E10.51, E10.52, E11.51, E11.52, E13.51, E13.52, I70.0, I70.1, Vascular disease 108
I70.20-, I70.21-, I70.22-, I70.29-, I70.30-, I70.31-, I70.32-, I70.39-, I70.40, I70.41-, I70.42-, I70.49-,
I70.50-, I70.51-, I70.52-, I70.59-, I70.60-, I70.61-, I70.62-, I70.69-, I70.70-, I70.71-, I70.72-, I70.79-,
I70.92, I71.2, I71.4, I71.6, I71.9, I72.-, I73.1, I73.8-, I73.9, I77.0-I77.6, I77.81-, I77.89, I77.9, I78.0,
I79.-, I80.1-, I80.20-, I80.21-, I80.23-, I80.29-, I82.0, I82.21-, I82.22-, I82.29-, I82.3, I82.40-,
I82.41-, I82.42-, I82.43-, I82.44-, I82.49-, I82.4Y-, I82.4Z-, I82.50-, I82.51-, I82.52-, I82.53-, I82.54-,
I82.59-, I82.5Y-, I82.5Z-, I82.62-, I82.72-, I82.A1-, I82.A2-, I82.B1-, I82.B2-, I82.C1-, I82.C2-, K55.1,
K55.8, K55.9, M31.8, M31.9
E84.0, E84.1-, E84.8, E84.9 Cystic fibrosis 110 111,112
J41.0-J41.8, J42, J43.-, J44.-, J98.2, J98.3 Chronic obstructive 111 112
pulmonary disease
B44.81, D86.0, D86.2, J47.-, J60-J68.-, J70.-, J82, J84.0-, J84.10, J84.11-, J84.17, J84.2, J84.8-, Fibrosis of lung and other 112
J84.9, J99, M32.13, M33.01, M33.11, M33.21, M33.91, M34.81, M35.02 chronic lung disorders
A48.1, J15.0-J15.2-, J15.5, J15.6, J15.8, J69.-, J95.851 Aspiration and specified 114 115
bacterial pneumonias
A01.03, A02.22, A06.5, A20.2, A21.2, A22.1, A42.0, A43.0, A54.84, B38.0-B38.2, B39.0, B39.1, Pneumococcal pneumonia, 115
B39.2, B40.0-B40.2, B41.0, B66.4, B67.1, J13, J14, J15.3, J15.4, J18.1, J85.-, J86.0, J86.9 empyema, lung abscess
E08.35-, E09.35-, E10.35-, E11.35-, E13.35-, H43.1- Proliferative diabetic 122
retinopathy and vitreous
hemorrhage
H35.32- Exudative macular 124
degeneration
T81.502(A)(D)(S), T81.512(A)(D)(S), T81.522(A)(D)(S), T81.532(A)(D)(S), T81.592(A)(D)(S), Dialysis status 134 135, 136,
T82.41X(A)(D)(S), T82.42X(A)(D)(S), T82.43X(A)(D)(S), T82.49X(A)(D)(S), T85.611(A)(D)(S), 137, 138
T85.621(A)(D)(S), T85.631(A)(D)(S), T85.691(A)(D)(S), T85.71X(A)(D)(S), Y62.2, Z49.0-, Z49.3-,
Z91.15, Z99.2
N17.- Acute renal failure 135 136, 137,
138
I12.0, I13.11, I13.2, N18.5, N18.6 Chronic kidney disease 136 137, 138
(stage 5)
 Disease
ICD-10-CM codes HCC category description HCC hierarchy
N18.4 Chronic kidney disease, 137 138
severe (stage 4)
N18.3 Chronic kidney disease, 138
moderate (stage 3)
L89.004, L89.014, L89.024, L89.104, L89.114, L89.124, L89.134, L89.144, L89.154, L89.204, Pressure ulcer of skin with 157 158, 161
L89.214, L89.224, L89.304, L89.314, L89.324, L89.44, L89.504, L89.514, L89.524, L89.604, necrosis through to muscle,
L89.614, L89.624, L89.814, L89.894, L89.94 tendon, bone
L89.000-L89.023, L89.100-L89.153, L89.200-L89.223, L89.300-L89.323, L89.4-, L89.500-L89.523, Pressure ulcer of skin with 158 161
L89.600-L89.623, L89.810-L89.893, L89.9- full thickness skin loss
L89.002, L89.012, L89.022, L89.102, L89.112, L89.122, L89.132, L89.142, L89.152, L89.202, Pressure ulcer of skin with 159
L89.212, L89.222, L89.302, L89.312, L89.322, L89.42, L89.502, L89.512, L89.522, L89.602, partial thickness skin loss
L89.612, L89.622, L89.812, L89.892, L89.92
E08.621, E08.622, E09.621, E09.622, E10.621, E10.622, E11.621, E11.622, E13.621, E13.622, Chronic ulcer of skin, except 161
I70.231-I70.25, I70.331-I70.35, I70.431-I70.45, I70.531-I70.55, I70.631-I70.65, I70.731- I70.75 pressure
L12.3, L51.1-L51.3, T31.11, T31.21, T31.22, T31.31-T31.33, T31.41-T31.44, T31.51-T31.55, Severe skin burn or condition 162
T31.61-T31.66, T31.71-T31.77, T31.81-T31.88, T31.91-T31.99, T32.11, T32.21, T32.22,
T32.31-T32.33, T32.41-T32.44, T32.51-T32.55, T32.61-T32.66, T32.71-T32.77, T32.81-T32.88,
T32.91-T32.99
S06.1X3-S06.1X6(A), S06.2X3-S06.2X6(A), S06.303(A)-S06.306(A), S06.313-S06.316(A), Severe head injury 166 80, 167
S06.323-S06.326(A), S06.333-S06.336(A), S06.343-S06.346(A), S06.353-S06.356(A),
S06.363-S06.366(A), S06.373-S06.376(A), S06.383-S06.386(A), S06.4X3-S06.4X6(A),
S06.5X3-S06.5X6(A), S06.6X3-S06.6X6(A), S06.813-S06.816(A), S06.823-S06.826(A),
S06.893-S06.896(A), S06.9X3-S06.9X6(A)
S02.0XX(A)(B)(S), S02.10-(A)(B)(S), S02.11-(A)(B)(S), S02.19X(A)(B)(S), S02.4-(A)(B)(S), S02.9-(A)(B)(S), Major head injury 167
S06.0X0S, S06.0X1S, S06.0X9S, S06.1X0-S06.1X2(A)(S), S06.1X3- S06.1X6(S), S06.1X9(A)(S),
S06.2X0-S06.2X2(A)(S), S06.2X3-S06.2X6(S), S06.2X9(A)(S), S06.300-S06.302(A)(S),
S06.303-S06.306(S), S06.309(A)(S), S06.310-S06.312(A)(S), S06.313-S06.316(S), S06.319(A)(S),
S06.320-S06.322(A)(S), S06.323-S06.326(S), S06.329(A)(S), S06.330-S06.332(A)(S),
S06.333-S06.336(S), S06.339(A)(S), S06.340-S06.342(A)(S), S06.343-S06.346(S), S06.349(A)(S),
S06.350-S06.352(A)(S), S06.353-S06.356(S), S06.359(A)(S), S06.360-S06.362(A)(S),
S06.363-S06.366(S), S06.369(A)(S), S06.370-S06.372(A)(S), S06.373-S06.376(S), S06.379(A)(S),
S06.380-S06.382(A)(S), S06.383-S06.386(S), S06.389(A)(S), S06.4X0-S06.4X2(A)(S),
S06.4X3-S06.4X6(S), S06.4X9(A)(S), S06.5X0-S06.5X2(A)(S), S06.5X3-S06.5X6(S), S06.5X9(A)(S),
S06.6X0-S06.6X2(A)(S), S06.6X3-S06.6X6(S), S06.6X9(A)(S), S06.810-S06.812(A)(S),
S06.813-S06.816(S), S06.819(A)(S), S06.820-S06.822(A)(S), S06.823-S06.826(S), S06.829(A)(S),
S06.890-S06.892(A)(S), S06.893-S06.896(S), S06.899(A)(S), S06.9X0-S06.9X2(A)(S),
S06.9X3-S06.9X6(S), S06.9X9(A)(S)
M48.5-(A), M80.08-(A), M80.88-(A), S12.0-(A)(B), S12.1-(A)(B), S12.2-(A)(B), S12.3-(A)(B), Vertebral fractures without 169
S12.4-(A)(B), S12.5-(A)(B), S12.6-(A)(B), S12.8XXA, S12.9XXA, S22.0-(A)(B), S32.0-(A)(B), spinal cord injury
S32.1-(A)(B), S32.2-(A)(B)
M80.05-(A), M80.85-(A), M84.451-M84.453(A), M84.459(A), M84.551-M84.559(A), Hip fracture/dislocation 170
M84.651-M84.659(A), S32.301-S32.9XX(A)(B), S72.001-S72.466(A)(B)(C), S72.47-(A),
S72.491-S72.92X(A)(B)(C), S73.0-(A), S79.001-S79.199(A)
S48.-(A), S58.-(A), S68.4-(A), S68.7-(A), S78.-(A), S88.-(A), S98.-(A), T79.-(A), T87.0X1-T87.2 Traumatic amputations and 173
complications
M96.6-, N99.5-, T82.3-(A), T82.510A, T82.511A, T82.513-T82.518(A), T82.520A, T82.521A, Complication of specified 176
T82.523-T82.528(A), T82.530A, T82.531-T82.538(A), T82.590A, T82.591A, T82.593-T82.598(A), implanted device or graft
T82.6XXA, T82.7XXA, T82.818A, T82.828A, T82.838A, T82.848A, T82.858A,T82.868A, T82.898A,
T83.0-T83.29X(A), T83.410-T83.718(A), T83.728A, T83.81X(A),T83.9XXA, T84.0-T84.9XX(A),
T85.0-(A), T85.1-(A), T85.6-(A), T85.7-(A), T85.8(A), T86.842
T86.0-, T86.2-, T86.3-, T86.4-, T86.5, T86.81-, T86.85-, Z48.21, Z48.23, Z48.24, Z48.280, Z48.290, Major organ transplant status 186
Z94.1-Z94.4, Z94.81-Z94.84, Z95.811, Z95.812 or replacement status
K91.85-, K94.-, Z43.1-Z43.9, Z93.1-Z93.9 Artificial openings for feeding 188
or elimination
G54.6, G54.7, S48.-(S), S58.-(S), S68.-(S), S78.-(D)(S), S88.-(D)(S), S98.-(D)(S), T87.30-T87.9, Amputation status, 189
Z44.101-Z44.109, Z44.111-Z44.119, Z44.121-Z44.129, Z89.411-Z89.419, Z89.421-Z89.429, lower limb/amputation
Z89.431-Z89.439, Z89.441-Z89.449, Z89.511-Z89.519, Z89.611-Z89.619 complication
Resources
Centers for Medicare and Medicaid Services (CMS), Medicare Advantage Rates & Statistics:
https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/index.html
Schmidt, A., Kenney, A., Krawzik, K., & Willard, P. (2018). ICD-10-CM Expert for Physicians 2019: The Complete Official Code Set.
Centers for Medicare and Medicaid Services. (2019, April 1). Announcement of Calendar Year (CY) 2020 Medicare Advantage Capitation
Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter. Retrieved from:
https://ww.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2019.pdf

This publication contains proprietary information. This material is for informational purposes only and is not guaranteed to be without
defect. Please reference the current version(s) of the ICD-10-CM codebook, CMS-HCC Risk Adjustment Model and AHA Coding Clinic for
complete code sets and official coding guidance. Redistribution or other use is strictly forbidden.
Coverage provided by Amerigroup Inc.
AGPCARE-0410-20 | 67337MUPENMUB