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HCCCategoryHCC Category Descriptor / Example Diagnoses2019 HCCValueICD-10Code1HIV/AIDS0.344Human immunodeficiency virus [HIV] diseaseB202Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock0.428Gram-negative sepsis, unspecifiedA41.50Sepsis, unspecified organismA41.96Opportunistic Infections0.446PneumocystisB598Metastatic Cancer and Acute Leukemia2.654Secondary malignant neoplasm of unspecified siteC79.99Lung and Other Severe Cancers1.027Malignant neoplasm of lower lobe, unspecified bronchus or lungC34.30Multiple myeloma in remissionC90.01Other Severe (e.g., Mesothelioma, Pancreas, Gallbladder, Liver, Stomach, Esophagus, Small intestine)10Lymphoma and Other Cancers0.675Secondary and unspecified malignant neoplasm of lymph node, unspecifiedC77.9Hodgkin lymphoma, unspecified, unspecified siteC81.90Unspecified B-cell lymphoma, unspecified siteC85.10Non-Hodgkin lymphoma, unspecified, unspecified siteC85.90Other (e.g., Brain, Endocrine, Ovary, Connective & Soft tissue, Peripheral nerves)11Colorectal, Bladder, and Other Cancers0.309Malignant neoplasm of colon, unspecifiedC18.9Malignant neoplasm of bladder, unspecifiedC67.9Malignant neoplasm of unspecified kidney, except renal pelvisC64.9Other (e.g., Mouth, Tongue, Salivary Glands, Nasopharynx, Sinuses, Ear, Labia, Cervix)12Breast, Prostate, and Other Cancers and Tumors0.153Malignant neoplasm of unspecified site of unspecified female breastC50.919Malignant neoplasm of prostateC61Malignant neoplasm of endometriumC54.1Other (e.g., Penis, Eye, Musculoskeletal, Melanoma, Brain benign, Merkel cell, Carcinoid)17Diabetes with Acute Complications0.307Type 1 diabetes mellitus with ketoacidosis without comaE10.10Type 2 diabetes mellitus with ketoacidosis without comaE11.1018Diabetes with Chronic Complications0.307Type 2 diabetes mellitus with diabetic chronic kidney diseaseE11.22Type 2 diabetes mellitus with other circulatory complicationsE11.5919Diabetes without Complication0.106Type 2 diabetes mellitus without complicationsE11.921Protein-Calorie Malnutrition0.554Mild protein-calorie malnutritionE44.122Morbid Obesity0.262Body mass index (BMI) 40.0-44.9, adultZ68.41Class 2 (BMI 35-39.9) severe obesity with serious comorbidity in adultE66.0123Other Significant Endocrine and Metabolic Disorders0.212Hyperparathyroidism, unspecifiedE21.3Secondary hyperparathyroidism of renal originN25.81HCCCategoryHCC Category Descriptor / Example Diagnoses2019 HCCValueICD-10Code27End-Stage Liver Disease0.913Chronic hepatic failure without comaK72.1028Cirrhosis of Liver0.381Alcoholic cirrhosis of liver without ascitesK70.30Other cirrhosis of liverK74.6929Chronic Hepatitis0.153Chronic viral hepatitis, unspecifiedB18.933Intestinal Obstruction/Perforation0.243Fecal impactionK56.4134Chronic Pancreatitis0.308Other chronic pancreatitisK86.135Inflammatory Bowel Disease0.315Crohn's disease, unspecified, without complicationsK50.90Other ulcerative colitis without complicationsK51.8039Bone/Join/Muscle Infections/Necrosis0.431Arthritis due to other bacteria, unspecified jointM00.80Direct infection of unspec. joint in infectious and parasitic diseases classified elsewhereM01.X0Other reactive arthropathies, unspecified siteM02.80Reactive arthropathy, unspecifiedM02.9Osteomyelitis, unspecifiedM86.940Rheumatoid Arthritis and Inflammatory Connective Tissue Disease0.426Other rheumatoid arthritis with rheumatoid factor of unspecified siteM05.80Rheumatoid arthritis with rheumatoid factor, unspecifiedM05.9Rheumatoid arthritis without rheumatoid factor, unspecified siteM06.0046Severe Hematological Disorders1.394Refractory anemia, unspecifiedD46.4Sickle-cell disease without crisisD57.147Disorders of Immunity0.683Antineoplastic chemotherapy induced pancytopeniaD61.810Neutropenia, unspecifiedD70.948Coagulation Defects and Other Specified Hematologic Disorders0.214Sickle-cell traitD57.3Antiphospholipid syndromeD68.61Senile PurpuraD69.2Thrombocytopenia, unspecifiedD69.654Drug/Alcohol Psychosis0.368Alcohol dependence with withdrawal deliriumF10.231Cannabis abuse with psychotic disorder, unspecifiedF12.15955Substance Use Disorder, Moderate/Severe, or Substance Use with Complications0.368Alcohol dependence, uncomplicatedF10.20Alcohol dependence, in remissionF10.21Opioid dependence, uncomplicatedF11.20Opioid dependence, in remissionF11.2156Substance Use Disorder, Mild, Except Alcohol and Cannabis0.368Drug abuse (can specify amphetamines, barbiturates, cocaine, hallucinogens, opioids, etc.)F19.10HCCCategoryHCC Category Descriptor / Example Diagnoses2019 HCCValueICD-10Code57Schizophrenia0.606Schizophrenia, unspecifiedF20.958Reactive and Unspecified Psychosis 0.546Atypical psychosisF29Unspecified psychosis not due to a substance or known physiological conditionF2959Major Depressive, Bipolar, and Paranoid Disorders0.353Major depressive disorder, recurrent, mildF33.060Personality Disorders0.353Personality disorder, Unspec. (others: Antisocial, Borderline, Manipulative, Narcissistic, etc.)F60.970Quadriplegia1.338Quadriplegia, unspecifiedG82.50Functional quadriplegiaR53.271Paraplegia1.121Paraplegia, unspecifiedG82.2072Spinal cord Disorders/ Injuries0.519Myelitis, unspecifiedG04.91Unspecified injury at unspecified level of thoracic spinal cord, subsequent encounterS24.109DUnspecified injury at unspecified level of thoracic spinal cord, sequelaS24.109SComplete lesion of unspecified level of lumbar spinal cord, sequelaS34.119SIncomplete lesion of unspecified level of lumbar spinal cord, subsequent encounterS34.129D73Amyotrophic Lateral Sclerosis and Other Motor Neuron Disease1.026Amyotrophic lateral sclerosisG12.2174Cerebral Palsy0.354G80.975Myasthenia Gravis/Myoneural Disorders and Guillain-Barre Syndrome, Inflammatory and Toxic Neuropathy0.491Myasthenia gravis without (acute) exacerbationG70.00Myoneural disorder, unspecifiedG70.976Muscular Dystrophy0.533G71.077Multiple Sclerosis0.441G3578Parkinson’s and Huntington’s Diseases0.686Parkinson's diseaseG20Huntington's diseaseG1079Seizure Disorders and Convulsions0.277Other seizuresG40.89Epilepsy, unspecified, not intractable, without status epilepticusG40.90980Coma, Brain Compression/Anoxic Damage0.575Persistent vegetative stateR40.3Anoxic brain damage, not elsewhere classifiedG93.182Respirator Dependence/Tracheostomy Status1.051Encounter for attention to tracheostomyZ43.0Dependence on respirator [ventilator] statusZ99.1183Respiratory Arrest0.404R09.284Cardio-Respiratory Failure and Shock0.314Chronic respiratory failure with hypoxiaJ96.11Chronic respiratory failure with hypercapniaJ96.12HCCCategoryHCC Category Descriptor / Example Diagnoses2019 HCCValueICD-10Code85Congestive Heart Failure0.310Hypertensive heart disease with heart failureI11.0Pulmonary hypertension, unspecifiedI27.20Cardiomyopathy, unspecifiedI42.9Unspecified systolic (congestive) heart failureI50.20Chronic systolic (congestive) heart failureI50.22Unspecified diastolic (congestive) heart failureI50.30Chronic diastolic (congestive) heart failureI50.32Heart failure, unspecifiedI50.986Acute Myocardial Infarction0.220Other myocardial infarction typeI21.A987Unstable Angina and Other Acute Ischemic Heart Disease0.219Unstable anginaI20.088Angina Pectoris0.143Angina pectoris, unspecifiedI20.9Stable anginaI20.896Specified Heart Arrhythmias0.271Unspecified atrial fibrillationI48.91Sick sinus syndromeI49.5Supraventricular TachycardiaI47.199Cerebral Hemorrhage0.276Other nontraumatic subarachnoid hemorrhageI60.8Other nontraumatic intracerebral hemorrhageI61.8100Ischemic or Unspecified Stroke0.276Cerebral infarction due to thrombosis of unspecified carotid arteryI63.039Cerebral infarction, unspecifiedI63.9103Hemiplegia/Hemiparesis0.498Hemiplegia and hemiparesis following unspec. cerebrovascular disease affecting unspec. sideI69.359104Monoplegia, Other Paralytic Syndromes0.368Monoplegia, unspecified affecting unspecified sideG83.30106Atherosclerosis of the Extremities with Ulceration or Gangrene1.537Gas gangreneA48.0Gangrene, not elsewhere classifiedI96107Vascular Disease with Complications0.401Chronic pulmonary embolismI27.82Embolism and thrombosis of arteries of extremities, unspecifiedI74.4Varicose veins of unspecified lower extremity with ulcer of unspecified siteI83.009108Vascular Disease0.305Atherosclerosis of aortaI70.0Unspecified atherosclerosis of native arteries of extremity, unspecified extremityI70.209Aortic aneurysm of unspecified site, without ruptureI71.9Peripheral vascular disease, unspecifiedI73.9Phlebitis & thrombophlebitis of unspecified deep vessels of unspecified lower extremityI80.209Acute embolism & thrombosis of unspecified deep veins of unspecified lower extremityI82.409Chronic embolism & thrombosis of unspecified deep veins of unspecified lowerI82.509HCCCategoryHCC Category Descriptor / Example Diagnoses2019 HCCValueICD-10Code110Cystic Fibrosis0.509Cystic fibrosis, unspecifiedE84.9111Chronic Obstructive Pulmonary Disease0.335Emphysema, unspecifiedJ43.9Chronic obstructive pulmonary disease, unspecifiedJ44.9112Fibrosis of Lung and Other Chronic Lung Disorders0.216Pulmonary fibrosis, unspecifiedJ84.10Interstitial pulmonary disease, unspecifiedJ84.9114Aspiration and Specified Bacterial Pneumonias0.612Pneumonitis due to inhalation of food and vomitJ69.0115Pneumococcal Pneumonia, Empyema, Lung Abscess0.164Pneumonia due to Streptococcus pneumoniaeJ13Abscess of lung with pneumoniaJ85.1122Proliferative Diabetic Retinopathy and Vitreous Hemorrhage0.232Vitreous hemorrhage, unspecified eyeH43.10Vitreous hemorrhage, bilateralH43.13124Exudative Macular Degeneration0.522Exudative age-related macular degeneration, unspecified eye, stage unspecifiedH35.3290134Dialysis Status0.474Other mechanical complication of intraperitoneal dialysis catheter, sequelaT85.691S135Acute Renal Failure0.474Other acute kidney failureN17.8136Chronic Kidney Disease, Stage 50.284N18.5137Chronic Kidney Disease, Severe (Stage 4)0.284N18.4138Chronic kidney disease, Moderate (Stage 3)0.068N18.3157Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone2.112Pressure ulcer of unspecified site, stage 4L89.94158Pressure Ulcer of Skin with Full Thickness Skin Loss1.153Pressure ulcer of unspecified site, stage 3L89.93Pressure ulcer of unspecified site, unstageableL89.95161Chronic Ulcer of Skin, Except Pressure0.551Non-pressure chronic ulcer of skin of other sites with unspecified severityL98.499162Severe Skin Burn or Condition0.262Burns involving 10-19% of body surface with 10-19% third degree burnsT31.11Stevens-Johnson syndromeL51.1166Severe Head Injury0.575Unspecified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounterS06.9X5A167Major Head Injury0.143Unspecified fracture of skull, sequelaS02.91XSUnspecified fracture of facial bones, sequelaS02.92XSDiffuse traumatic brain injury without loss of consciousness, sequelaS06.2X0SDiffuse traumatic brain injury with loss of consciousness of unspecified duration, sequelaS06.2X9STraumatic subdural hemorrhage without loss of consciousness, sequelaS06.5X0STraumatic subarachnoid hemorrhage without loss of consciousness, sequelaS06.6X0SHCCCategoryHCC Category Descriptor / Example Diagnoses2019 HCCValueICD-10Code169Vertebral Fractures without Spinal Cord Injury0.508Collapsed vertebra, not elsewhere classified, site unspec., initial encounter for fractureM48.50XAAge-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fractureM80.88XAFracture of neck, unspecified, initial encounterS12.9XXAWedge compression fracture of unspecified thoracic vertebra, initial encounter for closed fractureS22.000AOther fracture of sacrum, initial encounter for closed fractureS32.19XAFracture of coccyx, initial encounter for closed fractureS32.2XXAAge-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fractureM80.08XA170Hip Fracture/Dislocation0.406Pathological fracture, unspecified femur, initial encounter for fractureM84.453APathological fracture in neoplastic disease, hip, unspecified, initial encounter for fractureM84.559AUnspecified fracture of unspecified ilium, initial encounter for closed fractureS32.309AUnspecified fracture of unspecified acetabulum, initial encounter for closed fractureS32.409AUnspecified fracture of unspecified ischium, initial encounter for closed fractureS32.609AFracture of other parts of pelvis, initial encounter for closed fractureS32.89XA173Traumatic Amputations and Complications0.249Partial traumatic transmetacarpal amputation of unspecified hand, initial encounterS68.729APartial traumatic amputation of unspecified great toe, initial encounterS98129A176Complications of Specified Implanted Device or Graft0.609Other cystostomy complicationN99.518186Major Organ Transplant or Replacement Status0.855188Artificial Openings for Feeding or Elimination0.581Encounter for attention to gastrostomyZ43.1Encounter for attention to ileostomyZ43.2Encounter for attention to colostomyZ43.3Encounter for attention to cystostomyZ43.5189Amputation Status, Lower Limb/Amputation Complications0.567Phantom limb syndrome with painG54.6Partial traumatic transmetacarpal amputation of unspecified hand, sequelaS68.729SPartial traumatic amputation of unspecified great toe, subsequent encounterS98.129DCMS uses a Hierarchical Condition Category (HCC) risk adjustment model to calculate patient risk scores to predict health care costs. Scores are used to adjust capitated payments for beneficiaries enrolled in Medicare Advantage and to determine expected costs in Medicare Shared Savings Programs (ACOs).Total Risk Adjustment Factor (RAF) Score = Demographics + Diagnoses + InteractionsEach year CMS publishes a "denominator" to convert risk scores into dollar amounts. The 2019 denominator is $9,367.34. Multiplying the risk score by this denominator results in an estimated annual expenditure for a beneficiary.The diagnoses above often are “unspecified” only as examples. It is important to code to the highest level of specificity to achieve an accurate risk score. All active diagnoses need to be documented and resubmitted each year.E/M documentation must support all submitted diagnoses. Proper documentation of each diagnosis must demonstrate the provider is Monitoring, Evaluating, Assessing/Addressing, or Treating (MEAT) the condition yearly.Useful Tool: Risk score calculator resource--: HCC Risk Adjustment values vary based on beneficiary demographics, RA model, specificity of the diagnosis reported, and change year to year. Unspecified diagnosis code ranges are used throughout this resource simply as a reference point for you to then select the appropriate specified code based on your patient’s conditions. HCC values listed are based on the 2019 CMS HCC Model for community non-dual aged beneficiaries. ................
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