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ICD-10-CM Codes, CMS-HCC and RxHCC Models

Includes ICD-10 codes valid in FY2020 or FY2021.

Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

A0103 Typhoid pneumonia 115 115 115 Yes Yes Yes No


A0104 Typhoid arthritis 39 39 39 Yes Yes Yes No
A0105 Typhoid osteomyelitis 39 39 39 Yes Yes Yes No
A021 Salmonella sepsis 2 2 2 Yes Yes Yes No
A0222 Salmonella pneumonia 115 115 115 Yes Yes Yes No
A0223 Salmonella arthritis 39 39 39 Yes Yes Yes No
A0224 Salmonella osteomyelitis 39 39 39 Yes Yes Yes No
A065 Amebic lung abscess 115 115 115 Yes Yes Yes No
A072 Cryptosporidiosis 6 6 6 5 Yes Yes Yes Yes
A202 Pneumonic plague 115 115 115 Yes Yes Yes No
A207 Septicemic plague 2 2 2 Yes Yes Yes No
A212 Pulmonary tularemia 115 115 115 Yes Yes Yes No
A221 Pulmonary anthrax 115 115 115 Yes Yes Yes No
A227 Anthrax sepsis 2 2 2 Yes Yes Yes No
A267 Erysipelothrix sepsis 2 2 2 Yes Yes Yes No
A310 Pulmonary mycobacterial infection 6 6 6 5 Yes Yes Yes Yes
A312 Disseminated mycobacterium avium-intracellulare complex (DMAC) 6 6 6 5 Yes Yes Yes Yes
A327 Listerial sepsis 2 2 2 Yes Yes Yes No
A3681 Diphtheritic cardiomyopathy 85 85 85 186 Yes Yes Yes Yes
A3684 Diphtheritic tubulo-interstitial nephropathy 141 Yes No No No
A391 Waterhouse-Friderichsen syndrome 23 23 23 41 Yes Yes Yes Yes
A392 Acute meningococcemia 2 2 2 Yes Yes Yes No
A393 Chronic meningococcemia 2 2 2 Yes Yes Yes No
A394 Meningococcemia, unspecified 2 2 2 Yes Yes Yes No
A3983 Meningococcal arthritis 39 39 39 Yes Yes Yes No
A3984 Postmeningococcal arthritis 39 39 39 Yes Yes Yes No
A400 Sepsis due to streptococcus, group A 2 2 2 Yes Yes Yes No
A401 Sepsis due to streptococcus, group B 2 2 2 Yes Yes Yes No
A403 Sepsis due to Streptococcus pneumoniae 2 2 2 Yes Yes Yes No
A408 Other streptococcal sepsis 2 2 2 Yes Yes Yes No
A409 Streptococcal sepsis, unspecified 2 2 2 Yes Yes Yes No
A4101 Sepsis due to Methicillin susceptible Staphylococcus aureus 2 2 2 Yes Yes Yes No
A4102 Sepsis due to Methicillin resistant Staphylococcus aureus 2 2 2 Yes Yes Yes No
A411 Sepsis due to other specified staphylococcus 2 2 2 Yes Yes Yes No
A412 Sepsis due to unspecified staphylococcus 2 2 2 Yes Yes Yes No
A413 Sepsis due to Hemophilus influenzae 2 2 2 Yes Yes Yes No
A414 Sepsis due to anaerobes 2 2 2 Yes Yes Yes No
A4150 Gram-negative sepsis, unspecified 2 2 2 Yes Yes Yes No
A4151 Sepsis due to Escherichia coli [E. coli] 2 2 2 Yes Yes Yes No
A4152 Sepsis due to Pseudomonas 2 2 2 Yes Yes Yes No
A4153 Sepsis due to Serratia 2 2 2 Yes Yes Yes No
A4159 Other Gram-negative sepsis 2 2 2 Yes Yes Yes No
A4181 Sepsis due to Enterococcus 2 2 2 Yes Yes Yes No
A4189 Other specified sepsis 2 2 2 Yes Yes Yes No
A419 Sepsis, unspecified organism 2 2 2 Yes Yes Yes No
A420 Pulmonary actinomycosis 115 115 115 Yes Yes Yes No
A427 Actinomycotic sepsis 2 2 2 Yes Yes Yes No
A430 Pulmonary nocardiosis 115 115 115 Yes Yes Yes No

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Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

A480 Gas gangrene 106 106 106 Yes Yes Yes No


A481 Legionnaires' disease 114 114 114 Yes Yes Yes No
A483 Toxic shock syndrome 2 2 2 Yes Yes Yes No
A5055 Late congenital syphilitic arthropathy 39 39 39 Yes Yes Yes No
A5204 Syphilitic cerebral arteritis 206 No No No Yes
A5440 Gonococcal infection of musculoskeletal system, unspecified 39 39 39 Yes Yes Yes No
A5441 Gonococcal spondylopathy 39 39 39 Yes Yes Yes No
A5442 Gonococcal arthritis 39 39 39 Yes Yes Yes No
A5443 Gonococcal osteomyelitis 39 39 39 Yes Yes Yes No
A5449 Gonococcal infection of other musculoskeletal tissue 39 39 39 Yes Yes Yes No
A5484 Gonococcal pneumonia 115 115 115 Yes Yes Yes No
A5485 Gonococcal peritonitis 33 33 33 Yes Yes Yes No
A5486 Gonococcal sepsis 2 2 2 Yes Yes Yes No
A666 Bone and joint lesions of yaws 39 39 39 Yes Yes Yes No
A6923 Arthritis due to Lyme disease 39 39 39 Yes Yes Yes No
A8100 Creutzfeldt-Jakob disease, unspecified 52 52 112 Yes No Yes Yes
A8101 Variant Creutzfeldt-Jakob disease 52 52 112 Yes No Yes Yes
A8109 Other Creutzfeldt-Jakob disease 52 52 112 Yes No Yes Yes
A811 Subacute sclerosing panencephalitis 52 52 112 Yes No Yes Yes
A812 Progressive multifocal leukoencephalopathy 52 52 112 Yes No Yes Yes
A8181 Kuru 52 52 112 Yes No Yes Yes
A8182 Gerstmann-Straussler-Scheinker syndrome 52 52 112 Yes No Yes Yes
A8183 Fatal familial insomnia 52 52 112 Yes No Yes Yes
A8189 Other atypical virus infections of central nervous system 52 52 112 Yes No Yes Yes
A819 Atypical virus infection of central nervous system, unspecified 52 52 112 Yes No Yes Yes
A985 Hemorrhagic fever with renal syndrome 141 Yes No No No
B007 Disseminated herpesviral disease 2 2 2 Yes Yes Yes No
B0082 Herpes simplex myelitis 72 72 72 157 Yes Yes Yes Yes
B0112 Varicella myelitis 72 72 72 157 Yes Yes Yes Yes
B0221 Postherpetic geniculate ganglionitis 168 No No No Yes
B0222 Postherpetic trigeminal neuralgia 168 No No No Yes
B0223 Postherpetic polyneuropathy 168 No No No Yes
B0224 Postherpetic myelitis 72 72 72 157 Yes Yes Yes Yes
B0229 Other postherpetic nervous system involvement 168 No No No Yes
B0682 Rubella arthritis 39 39 39 Yes Yes Yes No
B180 Chronic viral hepatitis B with delta-agent 29 29 29 55 Yes Yes Yes Yes
B181 Chronic viral hepatitis B without delta-agent 29 29 29 55 Yes Yes Yes Yes
B182 Chronic viral hepatitis C 29 29 29 54 Yes Yes Yes Yes
B188 Other chronic viral hepatitis 29 29 29 55 Yes Yes Yes Yes
B189 Chronic viral hepatitis, unspecified 29 29 29 55 Yes Yes Yes Yes
B20 Human immunodeficiency virus [HIV] disease 1 1 1 1 Yes Yes Yes Yes
B250 Cytomegaloviral pneumonitis 6 6 6 5 Yes Yes Yes Yes
B251 Cytomegaloviral hepatitis 6 6 6 5 Yes Yes Yes Yes
B252 Cytomegaloviral pancreatitis 6 6 6 5 Yes Yes Yes Yes
B258 Other cytomegaloviral diseases 6 6 6 5 Yes Yes Yes Yes
B259 Cytomegaloviral disease, unspecified 6 6 6 5 Yes Yes Yes Yes
B2685 Mumps arthritis 39 39 39 Yes Yes Yes No
B3324 Viral cardiomyopathy 85 85 85 186 Yes Yes Yes Yes
B371 Pulmonary candidiasis 6 6 6 5 Yes Yes Yes Yes
B377 Candidal sepsis 2 2 2 5 Yes Yes Yes Yes
B377 Candidal sepsis 6 6 6 Yes Yes Yes --

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Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

B3781 Candidal esophagitis 6 6 6 5 Yes Yes Yes Yes


B380 Acute pulmonary coccidioidomycosis 115 115 115 Yes Yes Yes No
B381 Chronic pulmonary coccidioidomycosis 115 115 115 Yes Yes Yes No
B382 Pulmonary coccidioidomycosis, unspecified 115 115 115 Yes Yes Yes No
B390 Acute pulmonary histoplasmosis capsulati 115 115 115 Yes Yes Yes No
B391 Chronic pulmonary histoplasmosis capsulati 115 115 115 Yes Yes Yes No
B392 Pulmonary histoplasmosis capsulati, unspecified 115 115 115 Yes Yes Yes No
B400 Acute pulmonary blastomycosis 115 115 115 Yes Yes Yes No
B401 Chronic pulmonary blastomycosis 115 115 115 Yes Yes Yes No
B402 Pulmonary blastomycosis, unspecified 115 115 115 Yes Yes Yes No
B410 Pulmonary paracoccidioidomycosis 115 115 115 Yes Yes Yes No
B4282 Sporotrichosis arthritis 39 39 39 Yes Yes Yes No
B440 Invasive pulmonary aspergillosis 6 6 6 5 Yes Yes Yes Yes
B441 Other pulmonary aspergillosis 6 6 6 5 Yes Yes Yes Yes
B442 Tonsillar aspergillosis 6 6 6 5 Yes Yes Yes Yes
B447 Disseminated aspergillosis 6 6 6 5 Yes Yes Yes Yes
B4481 Allergic bronchopulmonary aspergillosis 112 112 112 227 Yes Yes Yes Yes
B4489 Other forms of aspergillosis 6 6 6 5 Yes Yes Yes Yes
B449 Aspergillosis, unspecified 6 6 6 5 Yes Yes Yes Yes
B450 Pulmonary cryptococcosis 6 6 6 5 Yes Yes Yes Yes
B451 Cerebral cryptococcosis 6 6 6 5 Yes Yes Yes Yes
B452 Cutaneous cryptococcosis 6 6 6 5 Yes Yes Yes Yes
B453 Osseous cryptococcosis 6 6 6 5 Yes Yes Yes Yes
B457 Disseminated cryptococcosis 6 6 6 5 Yes Yes Yes Yes
B458 Other forms of cryptococcosis 6 6 6 5 Yes Yes Yes Yes
B459 Cryptococcosis, unspecified 6 6 6 5 Yes Yes Yes Yes
B460 Pulmonary mucormycosis 6 6 6 5 Yes Yes Yes Yes
B461 Rhinocerebral mucormycosis 6 6 6 5 Yes Yes Yes Yes
B462 Gastrointestinal mucormycosis 6 6 6 5 Yes Yes Yes Yes
B463 Cutaneous mucormycosis 6 6 6 5 Yes Yes Yes Yes
B464 Disseminated mucormycosis 6 6 6 5 Yes Yes Yes Yes
B465 Mucormycosis, unspecified 6 6 6 5 Yes Yes Yes Yes
B468 Other zygomycoses 6 6 6 5 Yes Yes Yes Yes
B469 Zygomycosis, unspecified 6 6 6 5 Yes Yes Yes Yes
B484 Penicillosis 6 6 6 5 Yes Yes Yes Yes
B488 Other specified mycoses 6 6 6 5 Yes Yes Yes Yes
B520 Plasmodium malariae malaria with nephropathy 141 Yes No No No
B582 Toxoplasma meningoencephalitis 6 6 6 5 Yes Yes Yes Yes
B583 Pulmonary toxoplasmosis 6 6 6 5 Yes Yes Yes Yes
B59 Pneumocystosis 6 6 6 5 Yes Yes Yes Yes
B664 Paragonimiasis 115 115 115 Yes Yes Yes No
B671 Echinococcus granulosus infection of lung 115 115 115 Yes Yes Yes No
B9735 Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere 1 1 1 1 Yes Yes Yes Yes
C01 Malignant neoplasm of base of tongue 11 11 11 Yes Yes Yes No
C020 Malignant neoplasm of dorsal surface of tongue 11 11 11 Yes Yes Yes No
C021 Malignant neoplasm of border of tongue 11 11 11 Yes Yes Yes No
C022 Malignant neoplasm of ventral surface of tongue 11 11 11 Yes Yes Yes No
C023 Malignant neoplasm of anterior two-thirds of tongue, part unspecified 11 11 11 Yes Yes Yes No
C024 Malignant neoplasm of lingual tonsil 11 11 11 Yes Yes Yes No
C028 Malignant neoplasm of overlapping sites of tongue 11 11 11 Yes Yes Yes No
C029 Malignant neoplasm of tongue, unspecified 11 11 11 Yes Yes Yes No

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Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C030 Malignant neoplasm of upper gum 11 11 11 Yes Yes Yes No


C031 Malignant neoplasm of lower gum 11 11 11 Yes Yes Yes No
C039 Malignant neoplasm of gum, unspecified 11 11 11 Yes Yes Yes No
C040 Malignant neoplasm of anterior floor of mouth 11 11 11 Yes Yes Yes No
C041 Malignant neoplasm of lateral floor of mouth 11 11 11 Yes Yes Yes No
C048 Malignant neoplasm of overlapping sites of floor of mouth 11 11 11 Yes Yes Yes No
C049 Malignant neoplasm of floor of mouth, unspecified 11 11 11 Yes Yes Yes No
C050 Malignant neoplasm of hard palate 11 11 11 Yes Yes Yes No
C051 Malignant neoplasm of soft palate 11 11 11 Yes Yes Yes No
C052 Malignant neoplasm of uvula 11 11 11 Yes Yes Yes No
C058 Malignant neoplasm of overlapping sites of palate 11 11 11 Yes Yes Yes No
C059 Malignant neoplasm of palate, unspecified 11 11 11 Yes Yes Yes No
C060 Malignant neoplasm of cheek mucosa 11 11 11 Yes Yes Yes No
C061 Malignant neoplasm of vestibule of mouth 11 11 11 Yes Yes Yes No
C062 Malignant neoplasm of retromolar area 11 11 11 Yes Yes Yes No
C0680 Malignant neoplasm of overlapping sites of unspecified parts of mouth 11 11 11 Yes Yes Yes No
C0689 Malignant neoplasm of overlapping sites of other parts of mouth 11 11 11 Yes Yes Yes No
C069 Malignant neoplasm of mouth, unspecified 11 11 11 Yes Yes Yes No
C07 Malignant neoplasm of parotid gland 11 11 11 Yes Yes Yes No
C080 Malignant neoplasm of submandibular gland 11 11 11 Yes Yes Yes No
C081 Malignant neoplasm of sublingual gland 11 11 11 Yes Yes Yes No
C089 Malignant neoplasm of major salivary gland, unspecified 11 11 11 Yes Yes Yes No
C090 Malignant neoplasm of tonsillar fossa 11 11 11 Yes Yes Yes No
C091 Malignant neoplasm of tonsillar pillar (anterior) (posterior) 11 11 11 Yes Yes Yes No
C098 Malignant neoplasm of overlapping sites of tonsil 11 11 11 Yes Yes Yes No
C099 Malignant neoplasm of tonsil, unspecified 11 11 11 Yes Yes Yes No
C100 Malignant neoplasm of vallecula 11 11 11 Yes Yes Yes No
C101 Malignant neoplasm of anterior surface of epiglottis 11 11 11 Yes Yes Yes No
C102 Malignant neoplasm of lateral wall of oropharynx 11 11 11 Yes Yes Yes No
C103 Malignant neoplasm of posterior wall of oropharynx 11 11 11 Yes Yes Yes No
C104 Malignant neoplasm of branchial cleft 11 11 11 Yes Yes Yes No
C108 Malignant neoplasm of overlapping sites of oropharynx 11 11 11 Yes Yes Yes No
C109 Malignant neoplasm of oropharynx, unspecified 11 11 11 Yes Yes Yes No
C110 Malignant neoplasm of superior wall of nasopharynx 11 11 11 Yes Yes Yes No
C111 Malignant neoplasm of posterior wall of nasopharynx 11 11 11 Yes Yes Yes No
C112 Malignant neoplasm of lateral wall of nasopharynx 11 11 11 Yes Yes Yes No
C113 Malignant neoplasm of anterior wall of nasopharynx 11 11 11 Yes Yes Yes No
C118 Malignant neoplasm of overlapping sites of nasopharynx 11 11 11 Yes Yes Yes No
C119 Malignant neoplasm of nasopharynx, unspecified 11 11 11 Yes Yes Yes No
C12 Malignant neoplasm of pyriform sinus 11 11 11 Yes Yes Yes No
C130 Malignant neoplasm of postcricoid region 11 11 11 Yes Yes Yes No
C131 Malignant neoplasm of aryepiglottic fold, hypopharyngeal aspect 11 11 11 Yes Yes Yes No
C132 Malignant neoplasm of posterior wall of hypopharynx 11 11 11 Yes Yes Yes No
C138 Malignant neoplasm of overlapping sites of hypopharynx 11 11 11 Yes Yes Yes No
C139 Malignant neoplasm of hypopharynx, unspecified 11 11 11 Yes Yes Yes No
C140 Malignant neoplasm of pharynx, unspecified 11 11 11 Yes Yes Yes No
C142 Malignant neoplasm of Waldeyer's ring 11 11 11 Yes Yes Yes No
C148 Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx 11 11 11 Yes Yes Yes No
C153 Malignant neoplasm of upper third of esophagus 9 9 9 Yes Yes Yes No
C154 Malignant neoplasm of middle third of esophagus 9 9 9 Yes Yes Yes No
C155 Malignant neoplasm of lower third of esophagus 9 9 9 Yes Yes Yes No

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Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C158 Malignant neoplasm of overlapping sites of esophagus 9 9 9 Yes Yes Yes No


C159 Malignant neoplasm of esophagus, unspecified 9 9 9 Yes Yes Yes No
C160 Malignant neoplasm of cardia 9 9 9 18 Yes Yes Yes Yes
C161 Malignant neoplasm of fundus of stomach 9 9 9 18 Yes Yes Yes Yes
C162 Malignant neoplasm of body of stomach 9 9 9 18 Yes Yes Yes Yes
C163 Malignant neoplasm of pyloric antrum 9 9 9 18 Yes Yes Yes Yes
C164 Malignant neoplasm of pylorus 9 9 9 18 Yes Yes Yes Yes
C165 Malignant neoplasm of lesser curvature of stomach, unspecified 9 9 9 18 Yes Yes Yes Yes
C166 Malignant neoplasm of greater curvature of stomach, unspecified 9 9 9 18 Yes Yes Yes Yes
C168 Malignant neoplasm of overlapping sites of stomach 9 9 9 18 Yes Yes Yes Yes
C169 Malignant neoplasm of stomach, unspecified 9 9 9 18 Yes Yes Yes Yes
C170 Malignant neoplasm of duodenum 9 9 9 19 Yes Yes Yes Yes
C171 Malignant neoplasm of jejunum 9 9 9 19 Yes Yes Yes Yes
C172 Malignant neoplasm of ileum 9 9 9 19 Yes Yes Yes Yes
C173 Meckel's diverticulum, malignant 9 9 9 19 Yes Yes Yes Yes
C178 Malignant neoplasm of overlapping sites of small intestine 9 9 9 19 Yes Yes Yes Yes
C179 Malignant neoplasm of small intestine, unspecified 9 9 9 19 Yes Yes Yes Yes
C180 Malignant neoplasm of cecum 11 11 11 Yes Yes Yes No
C181 Malignant neoplasm of appendix 11 11 11 Yes Yes Yes No
C182 Malignant neoplasm of ascending colon 11 11 11 Yes Yes Yes No
C183 Malignant neoplasm of hepatic flexure 11 11 11 Yes Yes Yes No
C184 Malignant neoplasm of transverse colon 11 11 11 Yes Yes Yes No
C185 Malignant neoplasm of splenic flexure 11 11 11 Yes Yes Yes No
C186 Malignant neoplasm of descending colon 11 11 11 Yes Yes Yes No
C187 Malignant neoplasm of sigmoid colon 11 11 11 Yes Yes Yes No
C188 Malignant neoplasm of overlapping sites of colon 11 11 11 Yes Yes Yes No
C189 Malignant neoplasm of colon, unspecified 11 11 11 Yes Yes Yes No
C19 Malignant neoplasm of rectosigmoid junction 11 11 11 Yes Yes Yes No
C20 Malignant neoplasm of rectum 11 11 11 Yes Yes Yes No
C210 Malignant neoplasm of anus, unspecified 11 11 11 Yes Yes Yes No
C211 Malignant neoplasm of anal canal 11 11 11 Yes Yes Yes No
C212 Malignant neoplasm of cloacogenic zone 11 11 11 Yes Yes Yes No
C218 Malignant neoplasm of overlapping sites of rectum, anus and anal canal 11 11 11 Yes Yes Yes No
C220 Liver cell carcinoma 9 9 9 17 Yes Yes Yes Yes
C221 Intrahepatic bile duct carcinoma 9 9 9 17 Yes Yes Yes Yes
C222 Hepatoblastoma 9 9 9 17 Yes Yes Yes Yes
C223 Angiosarcoma of liver 9 9 9 17 Yes Yes Yes Yes
C224 Other sarcomas of liver 9 9 9 17 Yes Yes Yes Yes
C227 Other specified carcinomas of liver 9 9 9 17 Yes Yes Yes Yes
C228 Malignant neoplasm of liver, primary, unspecified as to type 9 9 9 17 Yes Yes Yes Yes
C229 Malignant neoplasm of liver, not specified as primary or secondary 9 9 9 17 Yes Yes Yes Yes
C23 Malignant neoplasm of gallbladder 9 9 9 19 Yes Yes Yes Yes
C240 Malignant neoplasm of extrahepatic bile duct 9 9 9 19 Yes Yes Yes Yes
C241 Malignant neoplasm of ampulla of Vater 9 9 9 19 Yes Yes Yes Yes
C248 Malignant neoplasm of overlapping sites of biliary tract 9 9 9 19 Yes Yes Yes Yes
C249 Malignant neoplasm of biliary tract, unspecified 9 9 9 19 Yes Yes Yes Yes
C250 Malignant neoplasm of head of pancreas 9 9 9 18 Yes Yes Yes Yes
C251 Malignant neoplasm of body of pancreas 9 9 9 18 Yes Yes Yes Yes
C252 Malignant neoplasm of tail of pancreas 9 9 9 18 Yes Yes Yes Yes
C253 Malignant neoplasm of pancreatic duct 9 9 9 18 Yes Yes Yes Yes
C254 Malignant neoplasm of endocrine pancreas 9 9 9 18 Yes Yes Yes Yes

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Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C257 Malignant neoplasm of other parts of pancreas 9 9 9 18 Yes Yes Yes Yes
C258 Malignant neoplasm of overlapping sites of pancreas 9 9 9 18 Yes Yes Yes Yes
C259 Malignant neoplasm of pancreas, unspecified 9 9 9 18 Yes Yes Yes Yes
C260 Malignant neoplasm of intestinal tract, part unspecified 11 11 11 Yes Yes Yes No
C261 Malignant neoplasm of spleen 11 11 11 Yes Yes Yes No
C269 Malignant neoplasm of ill-defined sites within the digestive system 11 11 11 Yes Yes Yes No
C300 Malignant neoplasm of nasal cavity 11 11 11 Yes Yes Yes No
C301 Malignant neoplasm of middle ear 11 11 11 Yes Yes Yes No
C310 Malignant neoplasm of maxillary sinus 11 11 11 Yes Yes Yes No
C311 Malignant neoplasm of ethmoidal sinus 11 11 11 Yes Yes Yes No
C312 Malignant neoplasm of frontal sinus 11 11 11 Yes Yes Yes No
C313 Malignant neoplasm of sphenoid sinus 11 11 11 Yes Yes Yes No
C318 Malignant neoplasm of overlapping sites of accessory sinuses 11 11 11 Yes Yes Yes No
C319 Malignant neoplasm of accessory sinus, unspecified 11 11 11 Yes Yes Yes No
C320 Malignant neoplasm of glottis 11 11 11 Yes Yes Yes No
C321 Malignant neoplasm of supraglottis 11 11 11 Yes Yes Yes No
C322 Malignant neoplasm of subglottis 11 11 11 Yes Yes Yes No
C323 Malignant neoplasm of laryngeal cartilage 11 11 11 Yes Yes Yes No
C328 Malignant neoplasm of overlapping sites of larynx 11 11 11 Yes Yes Yes No
C329 Malignant neoplasm of larynx, unspecified 11 11 11 Yes Yes Yes No
C33 Malignant neoplasm of trachea 9 9 9 18 Yes Yes Yes Yes
C3400 Malignant neoplasm of unspecified main bronchus 9 9 9 18 Yes Yes Yes Yes
C3401 Malignant neoplasm of right main bronchus 9 9 9 18 Yes Yes Yes Yes
C3402 Malignant neoplasm of left main bronchus 9 9 9 18 Yes Yes Yes Yes
C3410 Malignant neoplasm of upper lobe, unspecified bronchus or lung 9 9 9 18 Yes Yes Yes Yes
C3411 Malignant neoplasm of upper lobe, right bronchus or lung 9 9 9 18 Yes Yes Yes Yes
C3412 Malignant neoplasm of upper lobe, left bronchus or lung 9 9 9 18 Yes Yes Yes Yes
C342 Malignant neoplasm of middle lobe, bronchus or lung 9 9 9 18 Yes Yes Yes Yes
C3430 Malignant neoplasm of lower lobe, unspecified bronchus or lung 9 9 9 18 Yes Yes Yes Yes
C3431 Malignant neoplasm of lower lobe, right bronchus or lung 9 9 9 18 Yes Yes Yes Yes
C3432 Malignant neoplasm of lower lobe, left bronchus or lung 9 9 9 18 Yes Yes Yes Yes
C3480 Malignant neoplasm of overlapping sites of unspecified bronchus and lung 9 9 9 18 Yes Yes Yes Yes
C3481 Malignant neoplasm of overlapping sites of right bronchus and lung 9 9 9 18 Yes Yes Yes Yes
C3482 Malignant neoplasm of overlapping sites of left bronchus and lung 9 9 9 18 Yes Yes Yes Yes
C3490 Malignant neoplasm of unspecified part of unspecified bronchus or lung 9 9 9 18 Yes Yes Yes Yes
C3491 Malignant neoplasm of unspecified part of right bronchus or lung 9 9 9 18 Yes Yes Yes Yes
C3492 Malignant neoplasm of unspecified part of left bronchus or lung 9 9 9 18 Yes Yes Yes Yes
C37 Malignant neoplasm of thymus 11 11 11 Yes Yes Yes No
C380 Malignant neoplasm of heart 11 11 11 Yes Yes Yes No
C381 Malignant neoplasm of anterior mediastinum 11 11 11 Yes Yes Yes No
C382 Malignant neoplasm of posterior mediastinum 11 11 11 Yes Yes Yes No
C383 Malignant neoplasm of mediastinum, part unspecified 11 11 11 Yes Yes Yes No
C384 Malignant neoplasm of pleura 9 9 9 18 Yes Yes Yes Yes
C388 Malignant neoplasm of overlapping sites of heart, mediastinum and pleura 11 11 11 Yes Yes Yes No
C390 Malignant neoplasm of upper respiratory tract, part unspecified 11 11 11 Yes Yes Yes No
C399 Malignant neoplasm of lower respiratory tract, part unspecified 11 11 11 Yes Yes Yes No
C4000 Malignant neoplasm of scapula and long bones of unspecified upper limb 10 10 10 19 Yes Yes Yes Yes
C4001 Malignant neoplasm of scapula and long bones of right upper limb 10 10 10 19 Yes Yes Yes Yes
C4002 Malignant neoplasm of scapula and long bones of left upper limb 10 10 10 19 Yes Yes Yes Yes
C4010 Malignant neoplasm of short bones of unspecified upper limb 10 10 10 19 Yes Yes Yes Yes
C4011 Malignant neoplasm of short bones of right upper limb 10 10 10 19 Yes Yes Yes Yes

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Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C4012 Malignant neoplasm of short bones of left upper limb 10 10 10 19 Yes Yes Yes Yes
C4020 Malignant neoplasm of long bones of unspecified lower limb 10 10 10 19 Yes Yes Yes Yes
C4021 Malignant neoplasm of long bones of right lower limb 10 10 10 19 Yes Yes Yes Yes
C4022 Malignant neoplasm of long bones of left lower limb 10 10 10 19 Yes Yes Yes Yes
C4030 Malignant neoplasm of short bones of unspecified lower limb 10 10 10 19 Yes Yes Yes Yes
C4031 Malignant neoplasm of short bones of right lower limb 10 10 10 19 Yes Yes Yes Yes
C4032 Malignant neoplasm of short bones of left lower limb 10 10 10 19 Yes Yes Yes Yes
C4080 Malignant neoplasm of overlapping sites of bone and articular cartilage of unspecified limb 10 10 10 19 Yes Yes Yes Yes
C4081 Malignant neoplasm of overlapping sites of bone and articular cartilage of right limb 10 10 10 19 Yes Yes Yes Yes
C4082 Malignant neoplasm of overlapping sites of bone and articular cartilage of left limb 10 10 10 19 Yes Yes Yes Yes
C4090 Malignant neoplasm of unspecified bones and articular cartilage of unspecified limb 10 10 10 19 Yes Yes Yes Yes
C4091 Malignant neoplasm of unspecified bones and articular cartilage of right limb 10 10 10 19 Yes Yes Yes Yes
C4092 Malignant neoplasm of unspecified bones and articular cartilage of left limb 10 10 10 19 Yes Yes Yes Yes
C410 Malignant neoplasm of bones of skull and face 10 10 10 19 Yes Yes Yes Yes
C411 Malignant neoplasm of mandible 10 10 10 19 Yes Yes Yes Yes
C412 Malignant neoplasm of vertebral column 10 10 10 19 Yes Yes Yes Yes
C413 Malignant neoplasm of ribs, sternum and clavicle 10 10 10 19 Yes Yes Yes Yes
C414 Malignant neoplasm of pelvic bones, sacrum and coccyx 10 10 10 19 Yes Yes Yes Yes
C419 Malignant neoplasm of bone and articular cartilage, unspecified 10 10 10 19 Yes Yes Yes Yes
C430 Malignant melanoma of lip 12 12 12 Yes Yes Yes No
C4310 Malignant melanoma of unspecified eyelid, including canthus 12 12 12 Yes Yes Yes No
C43111 Malignant melanoma of right upper eyelid, including canthus 12 12 12 Yes Yes Yes No
C43112 Malignant melanoma of right lower eyelid, including canthus 12 12 12 Yes Yes Yes No
C43121 Malignant melanoma of left upper eyelid, including canthus 12 12 12 Yes Yes Yes No
C43122 Malignant melanoma of left lower eyelid, including canthus 12 12 12 Yes Yes Yes No
C4320 Malignant melanoma of unspecified ear and external auricular canal 12 12 12 Yes Yes Yes No
C4321 Malignant melanoma of right ear and external auricular canal 12 12 12 Yes Yes Yes No
C4322 Malignant melanoma of left ear and external auricular canal 12 12 12 Yes Yes Yes No
C4330 Malignant melanoma of unspecified part of face 12 12 12 Yes Yes Yes No
C4331 Malignant melanoma of nose 12 12 12 Yes Yes Yes No
C4339 Malignant melanoma of other parts of face 12 12 12 Yes Yes Yes No
C434 Malignant melanoma of scalp and neck 12 12 12 Yes Yes Yes No
C4351 Malignant melanoma of anal skin 12 12 12 Yes Yes Yes No
C4352 Malignant melanoma of skin of breast 12 12 12 Yes Yes Yes No
C4359 Malignant melanoma of other part of trunk 12 12 12 Yes Yes Yes No
C4360 Malignant melanoma of unspecified upper limb, including shoulder 12 12 12 Yes Yes Yes No
C4361 Malignant melanoma of right upper limb, including shoulder 12 12 12 Yes Yes Yes No
C4362 Malignant melanoma of left upper limb, including shoulder 12 12 12 Yes Yes Yes No
C4370 Malignant melanoma of unspecified lower limb, including hip 12 12 12 Yes Yes Yes No
C4371 Malignant melanoma of right lower limb, including hip 12 12 12 Yes Yes Yes No
C4372 Malignant melanoma of left lower limb, including hip 12 12 12 Yes Yes Yes No
C438 Malignant melanoma of overlapping sites of skin 12 12 12 Yes Yes Yes No
C439 Malignant melanoma of skin, unspecified 12 12 12 Yes Yes Yes No
C450 Mesothelioma of pleura 9 9 9 18 Yes Yes Yes Yes
C451 Mesothelioma of peritoneum 9 9 9 18 Yes Yes Yes Yes
C452 Mesothelioma of pericardium 9 9 9 18 Yes Yes Yes Yes
C457 Mesothelioma of other sites 9 9 9 18 Yes Yes Yes Yes
C459 Mesothelioma, unspecified 9 9 9 18 Yes Yes Yes Yes
C460 Kaposi's sarcoma of skin 10 10 10 18 Yes Yes Yes Yes
C461 Kaposi's sarcoma of soft tissue 10 10 10 18 Yes Yes Yes Yes
C462 Kaposi's sarcoma of palate 10 10 10 18 Yes Yes Yes Yes

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Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C463 Kaposi's sarcoma of lymph nodes 10 10 10 18 Yes Yes Yes Yes


C464 Kaposi's sarcoma of gastrointestinal sites 10 10 10 18 Yes Yes Yes Yes
C4650 Kaposi's sarcoma of unspecified lung 10 10 10 18 Yes Yes Yes Yes
C4651 Kaposi's sarcoma of right lung 10 10 10 18 Yes Yes Yes Yes
C4652 Kaposi's sarcoma of left lung 10 10 10 18 Yes Yes Yes Yes
C467 Kaposi's sarcoma of other sites 10 10 10 18 Yes Yes Yes Yes
C469 Kaposi's sarcoma, unspecified 10 10 10 18 Yes Yes Yes Yes
C470 Malignant neoplasm of peripheral nerves of head, face and neck 10 10 10 19 Yes Yes Yes Yes
C4710 Malignant neoplasm of peripheral nerves of unspecified upper limb, including shoulder 10 10 10 19 Yes Yes Yes Yes
C4711 Malignant neoplasm of peripheral nerves of right upper limb, including shoulder 10 10 10 19 Yes Yes Yes Yes
C4712 Malignant neoplasm of peripheral nerves of left upper limb, including shoulder 10 10 10 19 Yes Yes Yes Yes
C4720 Malignant neoplasm of peripheral nerves of unspecified lower limb, including hip 10 10 10 19 Yes Yes Yes Yes
C4721 Malignant neoplasm of peripheral nerves of right lower limb, including hip 10 10 10 19 Yes Yes Yes Yes
C4722 Malignant neoplasm of peripheral nerves of left lower limb, including hip 10 10 10 19 Yes Yes Yes Yes
C473 Malignant neoplasm of peripheral nerves of thorax 10 10 10 19 Yes Yes Yes Yes
C474 Malignant neoplasm of peripheral nerves of abdomen 10 10 10 16 Yes Yes Yes Yes
C475 Malignant neoplasm of peripheral nerves of pelvis 10 10 10 19 Yes Yes Yes Yes
C476 Malignant neoplasm of peripheral nerves of trunk, unspecified 10 10 10 19 Yes Yes Yes Yes
C478 Malignant neoplasm of overlapping sites of peripheral nerves and autonomic nervous system 10 10 10 19 Yes Yes Yes Yes
C479 Malignant neoplasm of peripheral nerves and autonomic nervous system, unspecified 10 10 10 19 Yes Yes Yes Yes
C480 Malignant neoplasm of retroperitoneum 9 9 9 19 Yes Yes Yes Yes
C481 Malignant neoplasm of specified parts of peritoneum 9 9 9 19 Yes Yes Yes Yes
C482 Malignant neoplasm of peritoneum, unspecified 9 9 9 19 Yes Yes Yes Yes
C488 Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum 9 9 9 19 Yes Yes Yes Yes
C490 Malignant neoplasm of connective and soft tissue of head, face and neck 10 10 10 19 Yes Yes Yes Yes
C4910 Malignant neoplasm of connective and soft tissue of unspecified upper limb, including shoulder 10 10 10 19 Yes Yes Yes Yes
C4911 Malignant neoplasm of connective and soft tissue of right upper limb, including shoulder 10 10 10 19 Yes Yes Yes Yes
C4912 Malignant neoplasm of connective and soft tissue of left upper limb, including shoulder 10 10 10 19 Yes Yes Yes Yes
C4920 Malignant neoplasm of connective and soft tissue of unspecified lower limb, including hip 10 10 10 19 Yes Yes Yes Yes
C4921 Malignant neoplasm of connective and soft tissue of right lower limb, including hip 10 10 10 19 Yes Yes Yes Yes
C4922 Malignant neoplasm of connective and soft tissue of left lower limb, including hip 10 10 10 19 Yes Yes Yes Yes
C493 Malignant neoplasm of connective and soft tissue of thorax 10 10 10 19 Yes Yes Yes Yes
C494 Malignant neoplasm of connective and soft tissue of abdomen 10 10 10 16 Yes Yes Yes Yes
C495 Malignant neoplasm of connective and soft tissue of pelvis 10 10 10 19 Yes Yes Yes Yes
C496 Malignant neoplasm of connective and soft tissue of trunk, unspecified 10 10 10 19 Yes Yes Yes Yes
C498 Malignant neoplasm of overlapping sites of connective and soft tissue 10 10 10 19 Yes Yes Yes Yes
C499 Malignant neoplasm of connective and soft tissue, unspecified 10 10 10 19 Yes Yes Yes Yes
C49A0 Gastrointestinal stromal tumor, unspecified site 10 10 10 16 Yes Yes Yes Yes
C49A1 Gastrointestinal stromal tumor of esophagus 10 10 10 16 Yes Yes Yes Yes
C49A2 Gastrointestinal stromal tumor of stomach 10 10 10 16 Yes Yes Yes Yes
C49A3 Gastrointestinal stromal tumor of small intestine 10 10 10 16 Yes Yes Yes Yes
C49A4 Gastrointestinal stromal tumor of large intestine 10 10 10 16 Yes Yes Yes Yes
C49A5 Gastrointestinal stromal tumor of rectum 10 10 10 16 Yes Yes Yes Yes
C49A9 Gastrointestinal stromal tumor of other sites 10 10 10 16 Yes Yes Yes Yes
C4A0 Merkel cell carcinoma of lip 12 12 12 19 Yes Yes Yes Yes
C4A10 Merkel cell carcinoma of unspecified eyelid, including canthus 12 12 12 19 Yes Yes Yes Yes
C4A111 Merkel cell carcinoma of right upper eyelid, including canthus 12 12 12 19 Yes Yes Yes Yes
C4A112 Merkel cell carcinoma of right lower eyelid, including canthus 12 12 12 19 Yes Yes Yes Yes
C4A121 Merkel cell carcinoma of left upper eyelid, including canthus 12 12 12 19 Yes Yes Yes Yes
C4A122 Merkel cell carcinoma of left lower eyelid, including canthus 12 12 12 19 Yes Yes Yes Yes
C4A20 Merkel cell carcinoma of unspecified ear and external auricular canal 12 12 12 19 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 8 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C4A21 Merkel cell carcinoma of right ear and external auricular canal 12 12 12 19 Yes Yes Yes Yes
C4A22 Merkel cell carcinoma of left ear and external auricular canal 12 12 12 19 Yes Yes Yes Yes
C4A30 Merkel cell carcinoma of unspecified part of face 12 12 12 19 Yes Yes Yes Yes
C4A31 Merkel cell carcinoma of nose 12 12 12 19 Yes Yes Yes Yes
C4A39 Merkel cell carcinoma of other parts of face 12 12 12 19 Yes Yes Yes Yes
C4A4 Merkel cell carcinoma of scalp and neck 12 12 12 19 Yes Yes Yes Yes
C4A51 Merkel cell carcinoma of anal skin 12 12 12 19 Yes Yes Yes Yes
C4A52 Merkel cell carcinoma of skin of breast 12 12 12 19 Yes Yes Yes Yes
C4A59 Merkel cell carcinoma of other part of trunk 12 12 12 19 Yes Yes Yes Yes
C4A60 Merkel cell carcinoma of unspecified upper limb, including shoulder 12 12 12 19 Yes Yes Yes Yes
C4A61 Merkel cell carcinoma of right upper limb, including shoulder 12 12 12 19 Yes Yes Yes Yes
C4A62 Merkel cell carcinoma of left upper limb, including shoulder 12 12 12 19 Yes Yes Yes Yes
C4A70 Merkel cell carcinoma of unspecified lower limb, including hip 12 12 12 19 Yes Yes Yes Yes
C4A71 Merkel cell carcinoma of right lower limb, including hip 12 12 12 19 Yes Yes Yes Yes
C4A72 Merkel cell carcinoma of left lower limb, including hip 12 12 12 19 Yes Yes Yes Yes
C4A8 Merkel cell carcinoma of overlapping sites 12 12 12 19 Yes Yes Yes Yes
C4A9 Merkel cell carcinoma, unspecified 12 12 12 19 Yes Yes Yes Yes
C50011 Malignant neoplasm of nipple and areola, right female breast 12 12 12 19 Yes Yes Yes Yes
C50012 Malignant neoplasm of nipple and areola, left female breast 12 12 12 19 Yes Yes Yes Yes
C50019 Malignant neoplasm of nipple and areola, unspecified female breast 12 12 12 19 Yes Yes Yes Yes
C50021 Malignant neoplasm of nipple and areola, right male breast 12 12 12 19 Yes Yes Yes Yes
C50022 Malignant neoplasm of nipple and areola, left male breast 12 12 12 19 Yes Yes Yes Yes
C50029 Malignant neoplasm of nipple and areola, unspecified male breast 12 12 12 19 Yes Yes Yes Yes
C50111 Malignant neoplasm of central portion of right female breast 12 12 12 19 Yes Yes Yes Yes
C50112 Malignant neoplasm of central portion of left female breast 12 12 12 19 Yes Yes Yes Yes
C50119 Malignant neoplasm of central portion of unspecified female breast 12 12 12 19 Yes Yes Yes Yes
C50121 Malignant neoplasm of central portion of right male breast 12 12 12 19 Yes Yes Yes Yes
C50122 Malignant neoplasm of central portion of left male breast 12 12 12 19 Yes Yes Yes Yes
C50129 Malignant neoplasm of central portion of unspecified male breast 12 12 12 19 Yes Yes Yes Yes
C50211 Malignant neoplasm of upper-inner quadrant of right female breast 12 12 12 19 Yes Yes Yes Yes
C50212 Malignant neoplasm of upper-inner quadrant of left female breast 12 12 12 19 Yes Yes Yes Yes
C50219 Malignant neoplasm of upper-inner quadrant of unspecified female breast 12 12 12 19 Yes Yes Yes Yes
C50221 Malignant neoplasm of upper-inner quadrant of right male breast 12 12 12 19 Yes Yes Yes Yes
C50222 Malignant neoplasm of upper-inner quadrant of left male breast 12 12 12 19 Yes Yes Yes Yes
C50229 Malignant neoplasm of upper-inner quadrant of unspecified male breast 12 12 12 19 Yes Yes Yes Yes
C50311 Malignant neoplasm of lower-inner quadrant of right female breast 12 12 12 19 Yes Yes Yes Yes
C50312 Malignant neoplasm of lower-inner quadrant of left female breast 12 12 12 19 Yes Yes Yes Yes
C50319 Malignant neoplasm of lower-inner quadrant of unspecified female breast 12 12 12 19 Yes Yes Yes Yes
C50321 Malignant neoplasm of lower-inner quadrant of right male breast 12 12 12 19 Yes Yes Yes Yes
C50322 Malignant neoplasm of lower-inner quadrant of left male breast 12 12 12 19 Yes Yes Yes Yes
C50329 Malignant neoplasm of lower-inner quadrant of unspecified male breast 12 12 12 19 Yes Yes Yes Yes
C50411 Malignant neoplasm of upper-outer quadrant of right female breast 12 12 12 19 Yes Yes Yes Yes
C50412 Malignant neoplasm of upper-outer quadrant of left female breast 12 12 12 19 Yes Yes Yes Yes
C50419 Malignant neoplasm of upper-outer quadrant of unspecified female breast 12 12 12 19 Yes Yes Yes Yes
C50421 Malignant neoplasm of upper-outer quadrant of right male breast 12 12 12 19 Yes Yes Yes Yes
C50422 Malignant neoplasm of upper-outer quadrant of left male breast 12 12 12 19 Yes Yes Yes Yes
C50429 Malignant neoplasm of upper-outer quadrant of unspecified male breast 12 12 12 19 Yes Yes Yes Yes
C50511 Malignant neoplasm of lower-outer quadrant of right female breast 12 12 12 19 Yes Yes Yes Yes
C50512 Malignant neoplasm of lower-outer quadrant of left female breast 12 12 12 19 Yes Yes Yes Yes
C50519 Malignant neoplasm of lower-outer quadrant of unspecified female breast 12 12 12 19 Yes Yes Yes Yes
C50521 Malignant neoplasm of lower-outer quadrant of right male breast 12 12 12 19 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 9 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C50522 Malignant neoplasm of lower-outer quadrant of left male breast 12 12 12 19 Yes Yes Yes Yes
C50529 Malignant neoplasm of lower-outer quadrant of unspecified male breast 12 12 12 19 Yes Yes Yes Yes
C50611 Malignant neoplasm of axillary tail of right female breast 12 12 12 19 Yes Yes Yes Yes
C50612 Malignant neoplasm of axillary tail of left female breast 12 12 12 19 Yes Yes Yes Yes
C50619 Malignant neoplasm of axillary tail of unspecified female breast 12 12 12 19 Yes Yes Yes Yes
C50621 Malignant neoplasm of axillary tail of right male breast 12 12 12 19 Yes Yes Yes Yes
C50622 Malignant neoplasm of axillary tail of left male breast 12 12 12 19 Yes Yes Yes Yes
C50629 Malignant neoplasm of axillary tail of unspecified male breast 12 12 12 19 Yes Yes Yes Yes
C50811 Malignant neoplasm of overlapping sites of right female breast 12 12 12 19 Yes Yes Yes Yes
C50812 Malignant neoplasm of overlapping sites of left female breast 12 12 12 19 Yes Yes Yes Yes
C50819 Malignant neoplasm of overlapping sites of unspecified female breast 12 12 12 19 Yes Yes Yes Yes
C50821 Malignant neoplasm of overlapping sites of right male breast 12 12 12 19 Yes Yes Yes Yes
C50822 Malignant neoplasm of overlapping sites of left male breast 12 12 12 19 Yes Yes Yes Yes
C50829 Malignant neoplasm of overlapping sites of unspecified male breast 12 12 12 19 Yes Yes Yes Yes
C50911 Malignant neoplasm of unspecified site of right female breast 12 12 12 19 Yes Yes Yes Yes
C50912 Malignant neoplasm of unspecified site of left female breast 12 12 12 19 Yes Yes Yes Yes
C50919 Malignant neoplasm of unspecified site of unspecified female breast 12 12 12 19 Yes Yes Yes Yes
C50921 Malignant neoplasm of unspecified site of right male breast 12 12 12 19 Yes Yes Yes Yes
C50922 Malignant neoplasm of unspecified site of left male breast 12 12 12 19 Yes Yes Yes Yes
C50929 Malignant neoplasm of unspecified site of unspecified male breast 12 12 12 19 Yes Yes Yes Yes
C510 Malignant neoplasm of labium majus 11 11 11 Yes Yes Yes No
C511 Malignant neoplasm of labium minus 11 11 11 Yes Yes Yes No
C512 Malignant neoplasm of clitoris 11 11 11 Yes Yes Yes No
C518 Malignant neoplasm of overlapping sites of vulva 11 11 11 Yes Yes Yes No
C519 Malignant neoplasm of vulva, unspecified 11 11 11 Yes Yes Yes No
C52 Malignant neoplasm of vagina 11 11 11 Yes Yes Yes No
C530 Malignant neoplasm of endocervix 11 11 11 Yes Yes Yes No
C531 Malignant neoplasm of exocervix 11 11 11 Yes Yes Yes No
C538 Malignant neoplasm of overlapping sites of cervix uteri 11 11 11 Yes Yes Yes No
C539 Malignant neoplasm of cervix uteri, unspecified 11 11 11 Yes Yes Yes No
C540 Malignant neoplasm of isthmus uteri 12 12 12 Yes Yes Yes No
C541 Malignant neoplasm of endometrium 12 12 12 Yes Yes Yes No
C542 Malignant neoplasm of myometrium 12 12 12 Yes Yes Yes No
C543 Malignant neoplasm of fundus uteri 12 12 12 Yes Yes Yes No
C548 Malignant neoplasm of overlapping sites of corpus uteri 12 12 12 Yes Yes Yes No
C549 Malignant neoplasm of corpus uteri, unspecified 12 12 12 Yes Yes Yes No
C55 Malignant neoplasm of uterus, part unspecified 12 12 12 Yes Yes Yes No
C561 Malignant neoplasm of right ovary 10 10 10 Yes Yes Yes No
C562 Malignant neoplasm of left ovary 10 10 10 Yes Yes Yes No
C569 Malignant neoplasm of unspecified ovary 10 10 10 Yes Yes Yes No
C5700 Malignant neoplasm of unspecified fallopian tube 10 10 10 Yes Yes Yes No
C5701 Malignant neoplasm of right fallopian tube 10 10 10 Yes Yes Yes No
C5702 Malignant neoplasm of left fallopian tube 10 10 10 Yes Yes Yes No
C5710 Malignant neoplasm of unspecified broad ligament 10 10 10 Yes Yes Yes No
C5711 Malignant neoplasm of right broad ligament 10 10 10 Yes Yes Yes No
C5712 Malignant neoplasm of left broad ligament 10 10 10 Yes Yes Yes No
C5720 Malignant neoplasm of unspecified round ligament 10 10 10 Yes Yes Yes No
C5721 Malignant neoplasm of right round ligament 10 10 10 Yes Yes Yes No
C5722 Malignant neoplasm of left round ligament 10 10 10 Yes Yes Yes No
C573 Malignant neoplasm of parametrium 10 10 10 Yes Yes Yes No
C574 Malignant neoplasm of uterine adnexa, unspecified 10 10 10 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 10 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C577 Malignant neoplasm of other specified female genital organs 11 11 11 Yes Yes Yes No
C578 Malignant neoplasm of overlapping sites of female genital organs 11 11 11 Yes Yes Yes No
C579 Malignant neoplasm of female genital organ, unspecified 11 11 11 Yes Yes Yes No
C58 Malignant neoplasm of placenta 10 10 10 Yes Yes Yes No
C600 Malignant neoplasm of prepuce 12 12 12 Yes Yes Yes No
C601 Malignant neoplasm of glans penis 12 12 12 Yes Yes Yes No
C602 Malignant neoplasm of body of penis 12 12 12 Yes Yes Yes No
C608 Malignant neoplasm of overlapping sites of penis 12 12 12 Yes Yes Yes No
C609 Malignant neoplasm of penis, unspecified 12 12 12 Yes Yes Yes No
C61 Malignant neoplasm of prostate 12 12 12 Yes Yes Yes No
C6200 Malignant neoplasm of unspecified undescended testis 12 12 12 Yes Yes Yes No
C6201 Malignant neoplasm of undescended right testis 12 12 12 Yes Yes Yes No
C6202 Malignant neoplasm of undescended left testis 12 12 12 Yes Yes Yes No
C6210 Malignant neoplasm of unspecified descended testis 12 12 12 Yes Yes Yes No
C6211 Malignant neoplasm of descended right testis 12 12 12 Yes Yes Yes No
C6212 Malignant neoplasm of descended left testis 12 12 12 Yes Yes Yes No
C6290 Malignant neoplasm of unspecified testis, unspecified whether descended or undescended 12 12 12 Yes Yes Yes No
C6291 Malignant neoplasm of right testis, unspecified whether descended or undescended 12 12 12 Yes Yes Yes No
C6292 Malignant neoplasm of left testis, unspecified whether descended or undescended 12 12 12 Yes Yes Yes No
C6300 Malignant neoplasm of unspecified epididymis 12 12 12 Yes Yes Yes No
C6301 Malignant neoplasm of right epididymis 12 12 12 Yes Yes Yes No
C6302 Malignant neoplasm of left epididymis 12 12 12 Yes Yes Yes No
C6310 Malignant neoplasm of unspecified spermatic cord 12 12 12 Yes Yes Yes No
C6311 Malignant neoplasm of right spermatic cord 12 12 12 Yes Yes Yes No
C6312 Malignant neoplasm of left spermatic cord 12 12 12 Yes Yes Yes No
C632 Malignant neoplasm of scrotum 12 12 12 Yes Yes Yes No
C637 Malignant neoplasm of other specified male genital organs 12 12 12 Yes Yes Yes No
C638 Malignant neoplasm of overlapping sites of male genital organs 12 12 12 Yes Yes Yes No
C639 Malignant neoplasm of male genital organ, unspecified 12 12 12 Yes Yes Yes No
C641 Malignant neoplasm of right kidney, except renal pelvis 11 11 11 18 Yes Yes Yes Yes
C642 Malignant neoplasm of left kidney, except renal pelvis 11 11 11 18 Yes Yes Yes Yes
C649 Malignant neoplasm of unspecified kidney, except renal pelvis 11 11 11 18 Yes Yes Yes Yes
C651 Malignant neoplasm of right renal pelvis 11 11 11 18 Yes Yes Yes Yes
C652 Malignant neoplasm of left renal pelvis 11 11 11 18 Yes Yes Yes Yes
C659 Malignant neoplasm of unspecified renal pelvis 11 11 11 18 Yes Yes Yes Yes
C661 Malignant neoplasm of right ureter 11 11 11 Yes Yes Yes No
C662 Malignant neoplasm of left ureter 11 11 11 Yes Yes Yes No
C669 Malignant neoplasm of unspecified ureter 11 11 11 Yes Yes Yes No
C670 Malignant neoplasm of trigone of bladder 11 11 11 Yes Yes Yes No
C671 Malignant neoplasm of dome of bladder 11 11 11 Yes Yes Yes No
C672 Malignant neoplasm of lateral wall of bladder 11 11 11 Yes Yes Yes No
C673 Malignant neoplasm of anterior wall of bladder 11 11 11 Yes Yes Yes No
C674 Malignant neoplasm of posterior wall of bladder 11 11 11 Yes Yes Yes No
C675 Malignant neoplasm of bladder neck 11 11 11 Yes Yes Yes No
C676 Malignant neoplasm of ureteric orifice 11 11 11 Yes Yes Yes No
C677 Malignant neoplasm of urachus 11 11 11 Yes Yes Yes No
C678 Malignant neoplasm of overlapping sites of bladder 11 11 11 Yes Yes Yes No
C679 Malignant neoplasm of bladder, unspecified 11 11 11 Yes Yes Yes No
C680 Malignant neoplasm of urethra 11 11 11 Yes Yes Yes No
C681 Malignant neoplasm of paraurethral glands 11 11 11 Yes Yes Yes No
C688 Malignant neoplasm of overlapping sites of urinary organs 11 11 11 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 11 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C689 Malignant neoplasm of urinary organ, unspecified 11 11 11 Yes Yes Yes No


C6900 Malignant neoplasm of unspecified conjunctiva 12 12 12 Yes Yes Yes No
C6901 Malignant neoplasm of right conjunctiva 12 12 12 Yes Yes Yes No
C6902 Malignant neoplasm of left conjunctiva 12 12 12 Yes Yes Yes No
C6910 Malignant neoplasm of unspecified cornea 12 12 12 Yes Yes Yes No
C6911 Malignant neoplasm of right cornea 12 12 12 Yes Yes Yes No
C6912 Malignant neoplasm of left cornea 12 12 12 Yes Yes Yes No
C6920 Malignant neoplasm of unspecified retina 12 12 12 Yes Yes Yes No
C6921 Malignant neoplasm of right retina 12 12 12 Yes Yes Yes No
C6922 Malignant neoplasm of left retina 12 12 12 Yes Yes Yes No
C6930 Malignant neoplasm of unspecified choroid 12 12 12 Yes Yes Yes No
C6931 Malignant neoplasm of right choroid 12 12 12 Yes Yes Yes No
C6932 Malignant neoplasm of left choroid 12 12 12 Yes Yes Yes No
C6940 Malignant neoplasm of unspecified ciliary body 12 12 12 Yes Yes Yes No
C6941 Malignant neoplasm of right ciliary body 12 12 12 Yes Yes Yes No
C6942 Malignant neoplasm of left ciliary body 12 12 12 Yes Yes Yes No
C6950 Malignant neoplasm of unspecified lacrimal gland and duct 12 12 12 Yes Yes Yes No
C6951 Malignant neoplasm of right lacrimal gland and duct 12 12 12 Yes Yes Yes No
C6952 Malignant neoplasm of left lacrimal gland and duct 12 12 12 Yes Yes Yes No
C6960 Malignant neoplasm of unspecified orbit 12 12 12 Yes Yes Yes No
C6961 Malignant neoplasm of right orbit 12 12 12 Yes Yes Yes No
C6962 Malignant neoplasm of left orbit 12 12 12 Yes Yes Yes No
C6980 Malignant neoplasm of overlapping sites of unspecified eye and adnexa 12 12 12 Yes Yes Yes No
C6981 Malignant neoplasm of overlapping sites of right eye and adnexa 12 12 12 Yes Yes Yes No
C6982 Malignant neoplasm of overlapping sites of left eye and adnexa 12 12 12 Yes Yes Yes No
C6990 Malignant neoplasm of unspecified site of unspecified eye 12 12 12 Yes Yes Yes No
C6991 Malignant neoplasm of unspecified site of right eye 12 12 12 Yes Yes Yes No
C6992 Malignant neoplasm of unspecified site of left eye 12 12 12 Yes Yes Yes No
C700 Malignant neoplasm of cerebral meninges 10 10 10 Yes Yes Yes No
C701 Malignant neoplasm of spinal meninges 10 10 10 Yes Yes Yes No
C709 Malignant neoplasm of meninges, unspecified 10 10 10 Yes Yes Yes No
C710 Malignant neoplasm of cerebrum, except lobes and ventricles 10 10 10 Yes Yes Yes No
C711 Malignant neoplasm of frontal lobe 10 10 10 Yes Yes Yes No
C712 Malignant neoplasm of temporal lobe 10 10 10 Yes Yes Yes No
C713 Malignant neoplasm of parietal lobe 10 10 10 Yes Yes Yes No
C714 Malignant neoplasm of occipital lobe 10 10 10 Yes Yes Yes No
C715 Malignant neoplasm of cerebral ventricle 10 10 10 Yes Yes Yes No
C716 Malignant neoplasm of cerebellum 10 10 10 Yes Yes Yes No
C717 Malignant neoplasm of brain stem 10 10 10 Yes Yes Yes No
C718 Malignant neoplasm of overlapping sites of brain 10 10 10 Yes Yes Yes No
C719 Malignant neoplasm of brain, unspecified 10 10 10 Yes Yes Yes No
C720 Malignant neoplasm of spinal cord 10 10 10 Yes Yes Yes No
C721 Malignant neoplasm of cauda equina 10 10 10 Yes Yes Yes No
C7220 Malignant neoplasm of unspecified olfactory nerve 10 10 10 Yes Yes Yes No
C7221 Malignant neoplasm of right olfactory nerve 10 10 10 Yes Yes Yes No
C7222 Malignant neoplasm of left olfactory nerve 10 10 10 Yes Yes Yes No
C7230 Malignant neoplasm of unspecified optic nerve 10 10 10 Yes Yes Yes No
C7231 Malignant neoplasm of right optic nerve 10 10 10 Yes Yes Yes No
C7232 Malignant neoplasm of left optic nerve 10 10 10 Yes Yes Yes No
C7240 Malignant neoplasm of unspecified acoustic nerve 10 10 10 Yes Yes Yes No
C7241 Malignant neoplasm of right acoustic nerve 10 10 10 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 12 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C7242 Malignant neoplasm of left acoustic nerve 10 10 10 Yes Yes Yes No


C7250 Malignant neoplasm of unspecified cranial nerve 10 10 10 Yes Yes Yes No
C7259 Malignant neoplasm of other cranial nerves 10 10 10 Yes Yes Yes No
C729 Malignant neoplasm of central nervous system, unspecified 10 10 10 Yes Yes Yes No
C73 Malignant neoplasm of thyroid gland 12 12 12 19 Yes Yes Yes Yes
C7400 Malignant neoplasm of cortex of unspecified adrenal gland 10 10 10 19 Yes Yes Yes Yes
C7401 Malignant neoplasm of cortex of right adrenal gland 10 10 10 19 Yes Yes Yes Yes
C7402 Malignant neoplasm of cortex of left adrenal gland 10 10 10 19 Yes Yes Yes Yes
C7410 Malignant neoplasm of medulla of unspecified adrenal gland 10 10 10 19 Yes Yes Yes Yes
C7411 Malignant neoplasm of medulla of right adrenal gland 10 10 10 19 Yes Yes Yes Yes
C7412 Malignant neoplasm of medulla of left adrenal gland 10 10 10 19 Yes Yes Yes Yes
C7490 Malignant neoplasm of unspecified part of unspecified adrenal gland 10 10 10 19 Yes Yes Yes Yes
C7491 Malignant neoplasm of unspecified part of right adrenal gland 10 10 10 19 Yes Yes Yes Yes
C7492 Malignant neoplasm of unspecified part of left adrenal gland 10 10 10 19 Yes Yes Yes Yes
C750 Malignant neoplasm of parathyroid gland 12 12 12 19 Yes Yes Yes Yes
C751 Malignant neoplasm of pituitary gland 10 10 10 Yes Yes Yes No
C752 Malignant neoplasm of craniopharyngeal duct 10 10 10 Yes Yes Yes No
C753 Malignant neoplasm of pineal gland 10 10 10 Yes Yes Yes No
C754 Malignant neoplasm of carotid body 12 12 12 19 Yes Yes Yes Yes
C755 Malignant neoplasm of aortic body and other paraganglia 12 12 12 19 Yes Yes Yes Yes
C758 Malignant neoplasm with pluriglandular involvement, unspecified 12 12 12 19 Yes Yes Yes Yes
C759 Malignant neoplasm of endocrine gland, unspecified 12 12 12 19 Yes Yes Yes Yes
C760 Malignant neoplasm of head, face and neck 12 12 12 Yes Yes Yes No
C761 Malignant neoplasm of thorax 12 12 12 Yes Yes Yes No
C762 Malignant neoplasm of abdomen 12 12 12 Yes Yes Yes No
C763 Malignant neoplasm of pelvis 12 12 12 Yes Yes Yes No
C7640 Malignant neoplasm of unspecified upper limb 12 12 12 Yes Yes Yes No
C7641 Malignant neoplasm of right upper limb 12 12 12 Yes Yes Yes No
C7642 Malignant neoplasm of left upper limb 12 12 12 Yes Yes Yes No
C7650 Malignant neoplasm of unspecified lower limb 12 12 12 Yes Yes Yes No
C7651 Malignant neoplasm of right lower limb 12 12 12 Yes Yes Yes No
C7652 Malignant neoplasm of left lower limb 12 12 12 Yes Yes Yes No
C768 Malignant neoplasm of other specified ill-defined sites 12 12 12 Yes Yes Yes No
C770 Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck 8 8 8 19 Yes Yes Yes Yes
C771 Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes 8 8 8 19 Yes Yes Yes Yes
C772 Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes 8 8 8 19 Yes Yes Yes Yes
C773 Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes 10 10 10 19 Yes Yes Yes Yes
C774 Secondary and unspecified malignant neoplasm of inguinal and lower limb lymph nodes 8 8 8 19 Yes Yes Yes Yes
C775 Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes 8 8 8 19 Yes Yes Yes Yes
C778 Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions 8 8 8 19 Yes Yes Yes Yes
C779 Secondary and unspecified malignant neoplasm of lymph node, unspecified 10 10 10 19 Yes Yes Yes Yes
C7800 Secondary malignant neoplasm of unspecified lung 8 8 8 17 Yes Yes Yes Yes
C7801 Secondary malignant neoplasm of right lung 8 8 8 17 Yes Yes Yes Yes
C7802 Secondary malignant neoplasm of left lung 8 8 8 17 Yes Yes Yes Yes
C781 Secondary malignant neoplasm of mediastinum 8 8 8 17 Yes Yes Yes Yes
C782 Secondary malignant neoplasm of pleura 8 8 8 17 Yes Yes Yes Yes
C7830 Secondary malignant neoplasm of unspecified respiratory organ 8 8 8 17 Yes Yes Yes Yes
C7839 Secondary malignant neoplasm of other respiratory organs 8 8 8 17 Yes Yes Yes Yes
C784 Secondary malignant neoplasm of small intestine 8 8 8 18 Yes Yes Yes Yes
C785 Secondary malignant neoplasm of large intestine and rectum 8 8 8 18 Yes Yes Yes Yes
C786 Secondary malignant neoplasm of retroperitoneum and peritoneum 8 8 8 18 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 13 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C787 Secondary malignant neoplasm of liver and intrahepatic bile duct 8 8 8 17 Yes Yes Yes Yes
C7880 Secondary malignant neoplasm of unspecified digestive organ 8 8 8 18 Yes Yes Yes Yes
C7889 Secondary malignant neoplasm of other digestive organs 8 8 8 18 Yes Yes Yes Yes
C7900 Secondary malignant neoplasm of unspecified kidney and renal pelvis 8 8 8 17 Yes Yes Yes Yes
C7901 Secondary malignant neoplasm of right kidney and renal pelvis 8 8 8 17 Yes Yes Yes Yes
C7902 Secondary malignant neoplasm of left kidney and renal pelvis 8 8 8 17 Yes Yes Yes Yes
C7910 Secondary malignant neoplasm of unspecified urinary organs 8 8 8 18 Yes Yes Yes Yes
C7911 Secondary malignant neoplasm of bladder 8 8 8 18 Yes Yes Yes Yes
C7919 Secondary malignant neoplasm of other urinary organs 8 8 8 18 Yes Yes Yes Yes
C792 Secondary malignant neoplasm of skin 10 10 10 18 Yes Yes Yes Yes
C7931 Secondary malignant neoplasm of brain 8 8 8 17 Yes Yes Yes Yes
C7932 Secondary malignant neoplasm of cerebral meninges 8 8 8 17 Yes Yes Yes Yes
C7940 Secondary malignant neoplasm of unspecified part of nervous system 8 8 8 17 Yes Yes Yes Yes
C7949 Secondary malignant neoplasm of other parts of nervous system 8 8 8 17 Yes Yes Yes Yes
C7951 Secondary malignant neoplasm of bone 8 8 8 17 Yes Yes Yes Yes
C7952 Secondary malignant neoplasm of bone marrow 8 8 8 17 Yes Yes Yes Yes
C7960 Secondary malignant neoplasm of unspecified ovary 8 8 8 18 Yes Yes Yes Yes
C7961 Secondary malignant neoplasm of right ovary 8 8 8 18 Yes Yes Yes Yes
C7962 Secondary malignant neoplasm of left ovary 8 8 8 18 Yes Yes Yes Yes
C7970 Secondary malignant neoplasm of unspecified adrenal gland 8 8 8 17 Yes Yes Yes Yes
C7971 Secondary malignant neoplasm of right adrenal gland 8 8 8 17 Yes Yes Yes Yes
C7972 Secondary malignant neoplasm of left adrenal gland 8 8 8 17 Yes Yes Yes Yes
C7981 Secondary malignant neoplasm of breast 10 10 10 18 Yes Yes Yes Yes
C7982 Secondary malignant neoplasm of genital organs 10 10 10 18 Yes Yes Yes Yes
C7989 Secondary malignant neoplasm of other specified sites 8 8 8 18 Yes Yes Yes Yes
C799 Secondary malignant neoplasm of unspecified site 8 8 8 18 Yes Yes Yes Yes
C7A00 Malignant carcinoid tumor of unspecified site 12 12 12 19 Yes Yes Yes Yes
C7A010 Malignant carcinoid tumor of the duodenum 12 12 12 19 Yes Yes Yes Yes
C7A011 Malignant carcinoid tumor of the jejunum 12 12 12 19 Yes Yes Yes Yes
C7A012 Malignant carcinoid tumor of the ileum 12 12 12 19 Yes Yes Yes Yes
C7A019 Malignant carcinoid tumor of the small intestine, unspecified portion 12 12 12 19 Yes Yes Yes Yes
C7A020 Malignant carcinoid tumor of the appendix 12 12 12 19 Yes Yes Yes Yes
C7A021 Malignant carcinoid tumor of the cecum 12 12 12 19 Yes Yes Yes Yes
C7A022 Malignant carcinoid tumor of the ascending colon 12 12 12 19 Yes Yes Yes Yes
C7A023 Malignant carcinoid tumor of the transverse colon 12 12 12 19 Yes Yes Yes Yes
C7A024 Malignant carcinoid tumor of the descending colon 12 12 12 19 Yes Yes Yes Yes
C7A025 Malignant carcinoid tumor of the sigmoid colon 12 12 12 19 Yes Yes Yes Yes
C7A026 Malignant carcinoid tumor of the rectum 12 12 12 19 Yes Yes Yes Yes
C7A029 Malignant carcinoid tumor of the large intestine, unspecified portion 12 12 12 19 Yes Yes Yes Yes
C7A090 Malignant carcinoid tumor of the bronchus and lung 12 12 12 19 Yes Yes Yes Yes
C7A091 Malignant carcinoid tumor of the thymus 12 12 12 19 Yes Yes Yes Yes
C7A092 Malignant carcinoid tumor of the stomach 12 12 12 19 Yes Yes Yes Yes
C7A093 Malignant carcinoid tumor of the kidney 12 12 12 19 Yes Yes Yes Yes
C7A094 Malignant carcinoid tumor of the foregut, unspecified 12 12 12 19 Yes Yes Yes Yes
C7A095 Malignant carcinoid tumor of the midgut, unspecified 12 12 12 19 Yes Yes Yes Yes
C7A096 Malignant carcinoid tumor of the hindgut, unspecified 12 12 12 19 Yes Yes Yes Yes
C7A098 Malignant carcinoid tumors of other sites 12 12 12 19 Yes Yes Yes Yes
C7A1 Malignant poorly differentiated neuroendocrine tumors 12 12 12 19 Yes Yes Yes Yes
C7A8 Other malignant neuroendocrine tumors 12 12 12 19 Yes Yes Yes Yes
C7B00 Secondary carcinoid tumors, unspecified site 8 8 8 18 Yes Yes Yes Yes
C7B01 Secondary carcinoid tumors of distant lymph nodes 8 8 8 19 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 14 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C7B02 Secondary carcinoid tumors of liver 8 8 8 17 Yes Yes Yes Yes


C7B03 Secondary carcinoid tumors of bone 8 8 8 17 Yes Yes Yes Yes
C7B04 Secondary carcinoid tumors of peritoneum 8 8 8 18 Yes Yes Yes Yes
C7B09 Secondary carcinoid tumors of other sites 8 8 8 18 Yes Yes Yes Yes
C7B1 Secondary Merkel cell carcinoma 8 8 8 18 Yes Yes Yes Yes
C7B8 Other secondary neuroendocrine tumors 8 8 8 18 Yes Yes Yes Yes
C800 Disseminated malignant neoplasm, unspecified 8 8 8 18 Yes Yes Yes Yes
C801 Malignant (primary) neoplasm, unspecified 12 12 12 Yes Yes Yes No
C802 Malignant neoplasm associated with transplanted organ 12 12 12 Yes Yes Yes No
C8100 Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site 10 10 10 Yes Yes Yes No
C8101 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8102 Nodular lymphocyte predominant Hodgkin lymphoma, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8103 Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8104 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8105 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of inguinal region and lower 10 10 10 Yes Yes Yes No
limb
C8106 Nodular lymphocyte predominant Hodgkin lymphoma, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8107 Nodular lymphocyte predominant Hodgkin lymphoma, spleen 10 10 10 Yes Yes Yes No
C8108 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8109 Nodular lymphocyte predominant Hodgkin lymphoma, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8110 Nodular sclerosis Hodgkin lymphoma, unspecified site 10 10 10 Yes Yes Yes No
C8111 Nodular sclerosis Hodgkin lymphoma, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8112 Nodular sclerosis Hodgkin lymphoma, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8113 Nodular sclerosis Hodgkin lymphoma, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8114 Nodular sclerosis Hodgkin lymphoma, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8115 Nodular sclerosis Hodgkin lymphoma, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8116 Nodular sclerosis Hodgkin lymphoma, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8117 Nodular sclerosis Hodgkin lymphoma, spleen 10 10 10 Yes Yes Yes No
C8118 Nodular sclerosis Hodgkin lymphoma, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8119 Nodular sclerosis Hodgkin lymphoma, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8120 Mixed cellularity Hodgkin lymphoma, unspecified site 10 10 10 Yes Yes Yes No
C8121 Mixed cellularity Hodgkin lymphoma, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8122 Mixed cellularity Hodgkin lymphoma, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8123 Mixed cellularity Hodgkin lymphoma, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8124 Mixed cellularity Hodgkin lymphoma, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8125 Mixed cellularity Hodgkin lymphoma, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8126 Mixed cellularity Hodgkin lymphoma, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8127 Mixed cellularity Hodgkin lymphoma, spleen 10 10 10 Yes Yes Yes No
C8128 Mixed cellularity Hodgkin lymphoma, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8129 Mixed cellularity Hodgkin lymphoma, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8130 Lymphocyte depleted Hodgkin lymphoma, unspecified site 10 10 10 Yes Yes Yes No
C8131 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8132 Lymphocyte depleted Hodgkin lymphoma, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8133 Lymphocyte depleted Hodgkin lymphoma, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8134 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8135 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8136 Lymphocyte depleted Hodgkin lymphoma, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8137 Lymphocyte depleted Hodgkin lymphoma, spleen 10 10 10 Yes Yes Yes No
C8138 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8139 Lymphocyte depleted Hodgkin lymphoma, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8140 Lymphocyte-rich Hodgkin lymphoma, unspecified site 10 10 10 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 15 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C8141 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8142 Lymphocyte-rich Hodgkin lymphoma, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8143 Lymphocyte-rich Hodgkin lymphoma, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8144 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8145 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8146 Lymphocyte-rich Hodgkin lymphoma, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8147 Lymphocyte-rich Hodgkin lymphoma, spleen 10 10 10 Yes Yes Yes No
C8148 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8149 Lymphocyte-rich Hodgkin lymphoma, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8170 Other Hodgkin lymphoma, unspecified site 10 10 10 Yes Yes Yes No
C8171 Other Hodgkin lymphoma, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8172 Other Hodgkin lymphoma, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8173 Other Hodgkin lymphoma, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8174 Other Hodgkin lymphoma, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8175 Other Hodgkin lymphoma, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8176 Other Hodgkin lymphoma, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8177 Other Hodgkin lymphoma, spleen 10 10 10 Yes Yes Yes No
C8178 Other Hodgkin lymphoma, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8179 Other Hodgkin lymphoma, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8190 Hodgkin lymphoma, unspecified, unspecified site 10 10 10 Yes Yes Yes No
C8191 Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8192 Hodgkin lymphoma, unspecified, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8193 Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8194 Hodgkin lymphoma, unspecified, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8195 Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8196 Hodgkin lymphoma, unspecified, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8197 Hodgkin lymphoma, unspecified, spleen 10 10 10 Yes Yes Yes No
C8198 Hodgkin lymphoma, unspecified, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8199 Hodgkin lymphoma, unspecified, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8200 Follicular lymphoma grade I, unspecified site 10 10 10 Yes Yes Yes No
C8201 Follicular lymphoma grade I, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8202 Follicular lymphoma grade I, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8203 Follicular lymphoma grade I, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8204 Follicular lymphoma grade I, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8205 Follicular lymphoma grade I, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8206 Follicular lymphoma grade I, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8207 Follicular lymphoma grade I, spleen 10 10 10 Yes Yes Yes No
C8208 Follicular lymphoma grade I, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8209 Follicular lymphoma grade I, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8210 Follicular lymphoma grade II, unspecified site 10 10 10 Yes Yes Yes No
C8211 Follicular lymphoma grade II, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8212 Follicular lymphoma grade II, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8213 Follicular lymphoma grade II, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8214 Follicular lymphoma grade II, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8215 Follicular lymphoma grade II, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8216 Follicular lymphoma grade II, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8217 Follicular lymphoma grade II, spleen 10 10 10 Yes Yes Yes No
C8218 Follicular lymphoma grade II, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8219 Follicular lymphoma grade II, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8220 Follicular lymphoma grade III, unspecified, unspecified site 10 10 10 Yes Yes Yes No
C8221 Follicular lymphoma grade III, unspecified, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 16 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C8222 Follicular lymphoma grade III, unspecified, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8223 Follicular lymphoma grade III, unspecified, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8224 Follicular lymphoma grade III, unspecified, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8225 Follicular lymphoma grade III, unspecified, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8226 Follicular lymphoma grade III, unspecified, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8227 Follicular lymphoma grade III, unspecified, spleen 10 10 10 Yes Yes Yes No
C8228 Follicular lymphoma grade III, unspecified, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8229 Follicular lymphoma grade III, unspecified, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8230 Follicular lymphoma grade IIIa, unspecified site 10 10 10 Yes Yes Yes No
C8231 Follicular lymphoma grade IIIa, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8232 Follicular lymphoma grade IIIa, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8233 Follicular lymphoma grade IIIa, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8234 Follicular lymphoma grade IIIa, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8235 Follicular lymphoma grade IIIa, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8236 Follicular lymphoma grade IIIa, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8237 Follicular lymphoma grade IIIa, spleen 10 10 10 Yes Yes Yes No
C8238 Follicular lymphoma grade IIIa, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8239 Follicular lymphoma grade IIIa, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8240 Follicular lymphoma grade IIIb, unspecified site 10 10 10 Yes Yes Yes No
C8241 Follicular lymphoma grade IIIb, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8242 Follicular lymphoma grade IIIb, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8243 Follicular lymphoma grade IIIb, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8244 Follicular lymphoma grade IIIb, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8245 Follicular lymphoma grade IIIb, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8246 Follicular lymphoma grade IIIb, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8247 Follicular lymphoma grade IIIb, spleen 10 10 10 Yes Yes Yes No
C8248 Follicular lymphoma grade IIIb, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8249 Follicular lymphoma grade IIIb, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8250 Diffuse follicle center lymphoma, unspecified site 10 10 10 Yes Yes Yes No
C8251 Diffuse follicle center lymphoma, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8252 Diffuse follicle center lymphoma, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8253 Diffuse follicle center lymphoma, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8254 Diffuse follicle center lymphoma, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8255 Diffuse follicle center lymphoma, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8256 Diffuse follicle center lymphoma, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8257 Diffuse follicle center lymphoma, spleen 10 10 10 Yes Yes Yes No
C8258 Diffuse follicle center lymphoma, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8259 Diffuse follicle center lymphoma, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8260 Cutaneous follicle center lymphoma, unspecified site 10 10 10 Yes Yes Yes No
C8261 Cutaneous follicle center lymphoma, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8262 Cutaneous follicle center lymphoma, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8263 Cutaneous follicle center lymphoma, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8264 Cutaneous follicle center lymphoma, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8265 Cutaneous follicle center lymphoma, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8266 Cutaneous follicle center lymphoma, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8267 Cutaneous follicle center lymphoma, spleen 10 10 10 Yes Yes Yes No
C8268 Cutaneous follicle center lymphoma, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8269 Cutaneous follicle center lymphoma, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8280 Other types of follicular lymphoma, unspecified site 10 10 10 Yes Yes Yes No
C8281 Other types of follicular lymphoma, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8282 Other types of follicular lymphoma, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 17 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C8283 Other types of follicular lymphoma, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8284 Other types of follicular lymphoma, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8285 Other types of follicular lymphoma, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8286 Other types of follicular lymphoma, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8287 Other types of follicular lymphoma, spleen 10 10 10 Yes Yes Yes No
C8288 Other types of follicular lymphoma, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8289 Other types of follicular lymphoma, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8290 Follicular lymphoma, unspecified, unspecified site 10 10 10 Yes Yes Yes No
C8291 Follicular lymphoma, unspecified, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8292 Follicular lymphoma, unspecified, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8293 Follicular lymphoma, unspecified, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8294 Follicular lymphoma, unspecified, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8295 Follicular lymphoma, unspecified, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8296 Follicular lymphoma, unspecified, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8297 Follicular lymphoma, unspecified, spleen 10 10 10 Yes Yes Yes No
C8298 Follicular lymphoma, unspecified, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8299 Follicular lymphoma, unspecified, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8300 Small cell B-cell lymphoma, unspecified site 10 10 10 Yes Yes Yes No
C8301 Small cell B-cell lymphoma, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8302 Small cell B-cell lymphoma, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8303 Small cell B-cell lymphoma, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8304 Small cell B-cell lymphoma, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8305 Small cell B-cell lymphoma, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8306 Small cell B-cell lymphoma, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8307 Small cell B-cell lymphoma, spleen 10 10 10 Yes Yes Yes No
C8308 Small cell B-cell lymphoma, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8309 Small cell B-cell lymphoma, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8310 Mantle cell lymphoma, unspecified site 10 10 10 Yes Yes Yes No
C8311 Mantle cell lymphoma, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8312 Mantle cell lymphoma, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8313 Mantle cell lymphoma, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8314 Mantle cell lymphoma, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8315 Mantle cell lymphoma, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8316 Mantle cell lymphoma, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8317 Mantle cell lymphoma, spleen 10 10 10 Yes Yes Yes No
C8318 Mantle cell lymphoma, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8319 Mantle cell lymphoma, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8330 Diffuse large B-cell lymphoma, unspecified site 10 10 10 Yes Yes Yes No
C8331 Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8332 Diffuse large B-cell lymphoma, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8333 Diffuse large B-cell lymphoma, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8334 Diffuse large B-cell lymphoma, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8335 Diffuse large B-cell lymphoma, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8336 Diffuse large B-cell lymphoma, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8337 Diffuse large B-cell lymphoma, spleen 10 10 10 Yes Yes Yes No
C8338 Diffuse large B-cell lymphoma, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8339 Diffuse large B-cell lymphoma, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8350 Lymphoblastic (diffuse) lymphoma, unspecified site 10 10 10 Yes Yes Yes No
C8351 Lymphoblastic (diffuse) lymphoma, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8352 Lymphoblastic (diffuse) lymphoma, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8353 Lymphoblastic (diffuse) lymphoma, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 18 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C8354 Lymphoblastic (diffuse) lymphoma, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8355 Lymphoblastic (diffuse) lymphoma, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8356 Lymphoblastic (diffuse) lymphoma, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8357 Lymphoblastic (diffuse) lymphoma, spleen 10 10 10 Yes Yes Yes No
C8358 Lymphoblastic (diffuse) lymphoma, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8359 Lymphoblastic (diffuse) lymphoma, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8370 Burkitt lymphoma, unspecified site 10 10 10 Yes Yes Yes No
C8371 Burkitt lymphoma, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8372 Burkitt lymphoma, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8373 Burkitt lymphoma, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8374 Burkitt lymphoma, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8375 Burkitt lymphoma, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8376 Burkitt lymphoma, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8377 Burkitt lymphoma, spleen 10 10 10 Yes Yes Yes No
C8378 Burkitt lymphoma, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8379 Burkitt lymphoma, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8380 Other non-follicular lymphoma, unspecified site 10 10 10 Yes Yes Yes No
C8381 Other non-follicular lymphoma, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8382 Other non-follicular lymphoma, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8383 Other non-follicular lymphoma, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8384 Other non-follicular lymphoma, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8385 Other non-follicular lymphoma, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8386 Other non-follicular lymphoma, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8387 Other non-follicular lymphoma, spleen 10 10 10 Yes Yes Yes No
C8388 Other non-follicular lymphoma, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8389 Other non-follicular lymphoma, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8390 Non-follicular (diffuse) lymphoma, unspecified, unspecified site 10 10 10 Yes Yes Yes No
C8391 Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8392 Non-follicular (diffuse) lymphoma, unspecified, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8393 Non-follicular (diffuse) lymphoma, unspecified, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8394 Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8395 Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8396 Non-follicular (diffuse) lymphoma, unspecified, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8397 Non-follicular (diffuse) lymphoma, unspecified, spleen 10 10 10 Yes Yes Yes No
C8398 Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8399 Non-follicular (diffuse) lymphoma, unspecified, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8400 Mycosis fungoides, unspecified site 10 10 10 18 Yes Yes Yes Yes
C8401 Mycosis fungoides, lymph nodes of head, face, and neck 10 10 10 18 Yes Yes Yes Yes
C8402 Mycosis fungoides, intrathoracic lymph nodes 10 10 10 18 Yes Yes Yes Yes
C8403 Mycosis fungoides, intra-abdominal lymph nodes 10 10 10 18 Yes Yes Yes Yes
C8404 Mycosis fungoides, lymph nodes of axilla and upper limb 10 10 10 18 Yes Yes Yes Yes
C8405 Mycosis fungoides, lymph nodes of inguinal region and lower limb 10 10 10 18 Yes Yes Yes Yes
C8406 Mycosis fungoides, intrapelvic lymph nodes 10 10 10 18 Yes Yes Yes Yes
C8407 Mycosis fungoides, spleen 10 10 10 18 Yes Yes Yes Yes
C8408 Mycosis fungoides, lymph nodes of multiple sites 10 10 10 18 Yes Yes Yes Yes
C8409 Mycosis fungoides, extranodal and solid organ sites 10 10 10 18 Yes Yes Yes Yes
C8410 Sezary disease, unspecified site 10 10 10 18 Yes Yes Yes Yes
C8411 Sezary disease, lymph nodes of head, face, and neck 10 10 10 18 Yes Yes Yes Yes
C8412 Sezary disease, intrathoracic lymph nodes 10 10 10 18 Yes Yes Yes Yes
C8413 Sezary disease, intra-abdominal lymph nodes 10 10 10 18 Yes Yes Yes Yes
C8414 Sezary disease, lymph nodes of axilla and upper limb 10 10 10 18 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 19 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C8415 Sezary disease, lymph nodes of inguinal region and lower limb 10 10 10 18 Yes Yes Yes Yes
C8416 Sezary disease, intrapelvic lymph nodes 10 10 10 18 Yes Yes Yes Yes
C8417 Sezary disease, spleen 10 10 10 18 Yes Yes Yes Yes
C8418 Sezary disease, lymph nodes of multiple sites 10 10 10 18 Yes Yes Yes Yes
C8419 Sezary disease, extranodal and solid organ sites 10 10 10 18 Yes Yes Yes Yes
C8440 Peripheral T-cell lymphoma, not classified, unspecified site 10 10 10 Yes Yes Yes No
C8441 Peripheral T-cell lymphoma, not classified, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8442 Peripheral T-cell lymphoma, not classified, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8443 Peripheral T-cell lymphoma, not classified, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8444 Peripheral T-cell lymphoma, not classified, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8445 Peripheral T-cell lymphoma, not classified, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8446 Peripheral T-cell lymphoma, not classified, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8447 Peripheral T-cell lymphoma, not classified, spleen 10 10 10 Yes Yes Yes No
C8448 Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8449 Peripheral T-cell lymphoma, not classified, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8460 Anaplastic large cell lymphoma, ALK-positive, unspecified site 10 10 10 Yes Yes Yes No
C8461 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8462 Anaplastic large cell lymphoma, ALK-positive, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8463 Anaplastic large cell lymphoma, ALK-positive, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8464 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8465 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8466 Anaplastic large cell lymphoma, ALK-positive, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8467 Anaplastic large cell lymphoma, ALK-positive, spleen 10 10 10 Yes Yes Yes No
C8468 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8469 Anaplastic large cell lymphoma, ALK-positive, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8470 Anaplastic large cell lymphoma, ALK-negative, unspecified site 10 10 10 Yes Yes Yes No
C8471 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8472 Anaplastic large cell lymphoma, ALK-negative, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8473 Anaplastic large cell lymphoma, ALK-negative, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8474 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8475 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8476 Anaplastic large cell lymphoma, ALK-negative, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8477 Anaplastic large cell lymphoma, ALK-negative, spleen 10 10 10 Yes Yes Yes No
C8478 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8479 Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8490 Mature T/NK-cell lymphomas, unspecified, unspecified site 10 10 10 Yes Yes Yes No
C8491 Mature T/NK-cell lymphomas, unspecified, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8492 Mature T/NK-cell lymphomas, unspecified, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8493 Mature T/NK-cell lymphomas, unspecified, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8494 Mature T/NK-cell lymphomas, unspecified, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8495 Mature T/NK-cell lymphomas, unspecified, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8496 Mature T/NK-cell lymphomas, unspecified, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8497 Mature T/NK-cell lymphomas, unspecified, spleen 10 10 10 Yes Yes Yes No
C8498 Mature T/NK-cell lymphomas, unspecified, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8499 Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C84A0 Cutaneous T-cell lymphoma, unspecified, unspecified site 10 10 10 Yes Yes Yes No
C84A1 Cutaneous T-cell lymphoma, unspecified lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C84A2 Cutaneous T-cell lymphoma, unspecified, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C84A3 Cutaneous T-cell lymphoma, unspecified, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C84A4 Cutaneous T-cell lymphoma, unspecified, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C84A5 Cutaneous T-cell lymphoma, unspecified, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 20 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C84A6 Cutaneous T-cell lymphoma, unspecified, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C84A7 Cutaneous T-cell lymphoma, unspecified, spleen 10 10 10 Yes Yes Yes No
C84A8 Cutaneous T-cell lymphoma, unspecified, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C84A9 Cutaneous T-cell lymphoma, unspecified, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C84Z0 Other mature T/NK-cell lymphomas, unspecified site 10 10 10 Yes Yes Yes No
C84Z1 Other mature T/NK-cell lymphomas, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C84Z2 Other mature T/NK-cell lymphomas, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C84Z3 Other mature T/NK-cell lymphomas, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C84Z4 Other mature T/NK-cell lymphomas, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C84Z5 Other mature T/NK-cell lymphomas, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C84Z6 Other mature T/NK-cell lymphomas, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C84Z7 Other mature T/NK-cell lymphomas, spleen 10 10 10 Yes Yes Yes No
C84Z8 Other mature T/NK-cell lymphomas, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C84Z9 Other mature T/NK-cell lymphomas, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8510 Unspecified B-cell lymphoma, unspecified site 10 10 10 Yes Yes Yes No
C8511 Unspecified B-cell lymphoma, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8512 Unspecified B-cell lymphoma, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8513 Unspecified B-cell lymphoma, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8514 Unspecified B-cell lymphoma, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8515 Unspecified B-cell lymphoma, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8516 Unspecified B-cell lymphoma, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8517 Unspecified B-cell lymphoma, spleen 10 10 10 Yes Yes Yes No
C8518 Unspecified B-cell lymphoma, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8519 Unspecified B-cell lymphoma, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8520 Mediastinal (thymic) large B-cell lymphoma, unspecified site 10 10 10 Yes Yes Yes No
C8521 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8522 Mediastinal (thymic) large B-cell lymphoma, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8523 Mediastinal (thymic) large B-cell lymphoma, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8524 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8525 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8526 Mediastinal (thymic) large B-cell lymphoma, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8527 Mediastinal (thymic) large B-cell lymphoma, spleen 10 10 10 Yes Yes Yes No
C8528 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8529 Mediastinal (thymic) large B-cell lymphoma, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8580 Other specified types of non-Hodgkin lymphoma, unspecified site 10 10 10 Yes Yes Yes No
C8581 Other specified types of non-Hodgkin lymphoma, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8582 Other specified types of non-Hodgkin lymphoma, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8583 Other specified types of non-Hodgkin lymphoma, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8584 Other specified types of non-Hodgkin lymphoma, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8585 Other specified types of non-Hodgkin lymphoma, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8586 Other specified types of non-Hodgkin lymphoma, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No
C8587 Other specified types of non-Hodgkin lymphoma, spleen 10 10 10 Yes Yes Yes No
C8588 Other specified types of non-Hodgkin lymphoma, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8589 Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C8590 Non-Hodgkin lymphoma, unspecified, unspecified site 10 10 10 Yes Yes Yes No
C8591 Non-Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck 10 10 10 Yes Yes Yes No
C8592 Non-Hodgkin lymphoma, unspecified, intrathoracic lymph nodes 10 10 10 Yes Yes Yes No
C8593 Non-Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes 10 10 10 Yes Yes Yes No
C8594 Non-Hodgkin lymphoma, unspecified, lymph nodes of axilla and upper limb 10 10 10 Yes Yes Yes No
C8595 Non-Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb 10 10 10 Yes Yes Yes No
C8596 Non-Hodgkin lymphoma, unspecified, intrapelvic lymph nodes 10 10 10 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 21 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
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Year

C8597 Non-Hodgkin lymphoma, unspecified, spleen 10 10 10 Yes Yes Yes No


C8598 Non-Hodgkin lymphoma, unspecified, lymph nodes of multiple sites 10 10 10 Yes Yes Yes No
C8599 Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites 10 10 10 Yes Yes Yes No
C860 Extranodal NK/T-cell lymphoma, nasal type 10 10 10 Yes Yes Yes No
C861 Hepatosplenic T-cell lymphoma 10 10 10 Yes Yes Yes No
C862 Enteropathy-type (intestinal) T-cell lymphoma 10 10 10 Yes Yes Yes No
C863 Subcutaneous panniculitis-like T-cell lymphoma 10 10 10 Yes Yes Yes No
C864 Blastic NK-cell lymphoma 10 10 10 Yes Yes Yes No
C865 Angioimmunoblastic T-cell lymphoma 10 10 10 Yes Yes Yes No
C866 Primary cutaneous CD30-positive T-cell proliferations 10 10 10 Yes Yes Yes No
C880 Waldenstrom macroglobulinemia 23 23 23 Yes Yes Yes No
C882 Heavy chain disease 10 10 10 Yes Yes Yes No
C883 Immunoproliferative small intestinal disease 10 10 10 Yes Yes Yes No
C884 Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma] 10 10 10 Yes Yes Yes No
C888 Other malignant immunoproliferative diseases 10 10 10 Yes Yes Yes No
C889 Malignant immunoproliferative disease, unspecified 10 10 10 Yes Yes Yes No
C9000 Multiple myeloma not having achieved remission 9 9 9 16 Yes Yes Yes Yes
C9001 Multiple myeloma in remission 9 9 9 16 Yes Yes Yes Yes
C9002 Multiple myeloma in relapse 9 9 9 16 Yes Yes Yes Yes
C9010 Plasma cell leukemia not having achieved remission 9 9 9 16 Yes Yes Yes Yes
C9011 Plasma cell leukemia in remission 9 9 9 16 Yes Yes Yes Yes
C9012 Plasma cell leukemia in relapse 9 9 9 16 Yes Yes Yes Yes
C9020 Extramedullary plasmacytoma not having achieved remission 9 9 9 16 Yes Yes Yes Yes
C9021 Extramedullary plasmacytoma in remission 9 9 9 16 Yes Yes Yes Yes
C9022 Extramedullary plasmacytoma in relapse 9 9 9 16 Yes Yes Yes Yes
C9030 Solitary plasmacytoma not having achieved remission 10 10 10 16 Yes Yes Yes Yes
C9031 Solitary plasmacytoma in remission 10 10 10 16 Yes Yes Yes Yes
C9032 Solitary plasmacytoma in relapse 10 10 10 16 Yes Yes Yes Yes
C9100 Acute lymphoblastic leukemia not having achieved remission 8 8 8 Yes Yes Yes No
C9101 Acute lymphoblastic leukemia, in remission 8 8 8 Yes Yes Yes No
C9102 Acute lymphoblastic leukemia, in relapse 8 8 8 Yes Yes Yes No
C9110 Chronic lymphocytic leukemia of B-cell type not having achieved remission 10 10 10 Yes Yes Yes No
C9111 Chronic lymphocytic leukemia of B-cell type in remission 10 10 10 Yes Yes Yes No
C9112 Chronic lymphocytic leukemia of B-cell type in relapse 10 10 10 Yes Yes Yes No
C9130 Prolymphocytic leukemia of B-cell type not having achieved remission 10 10 10 Yes Yes Yes No
C9131 Prolymphocytic leukemia of B-cell type, in remission 10 10 10 Yes Yes Yes No
C9132 Prolymphocytic leukemia of B-cell type, in relapse 10 10 10 Yes Yes Yes No
C9140 Hairy cell leukemia not having achieved remission 10 10 10 Yes Yes Yes No
C9141 Hairy cell leukemia, in remission 10 10 10 Yes Yes Yes No
C9142 Hairy cell leukemia, in relapse 10 10 10 Yes Yes Yes No
C9150 Adult T-cell lymphoma/leukemia (HTLV-1-associated) not having achieved remission 10 10 10 Yes Yes Yes No
C9151 Adult T-cell lymphoma/leukemia (HTLV-1-associated), in remission 10 10 10 Yes Yes Yes No
C9152 Adult T-cell lymphoma/leukemia (HTLV-1-associated), in relapse 10 10 10 Yes Yes Yes No
C9160 Prolymphocytic leukemia of T-cell type not having achieved remission 10 10 10 Yes Yes Yes No
C9161 Prolymphocytic leukemia of T-cell type, in remission 10 10 10 Yes Yes Yes No
C9162 Prolymphocytic leukemia of T-cell type, in relapse 10 10 10 Yes Yes Yes No
C9190 Lymphoid leukemia, unspecified not having achieved remission 10 10 10 Yes Yes Yes No
C9191 Lymphoid leukemia, unspecified, in remission 10 10 10 Yes Yes Yes No
C9192 Lymphoid leukemia, unspecified, in relapse 10 10 10 Yes Yes Yes No
C91A0 Mature B-cell leukemia Burkitt-type not having achieved remission 10 10 10 Yes Yes Yes No
C91A1 Mature B-cell leukemia Burkitt-type, in remission 10 10 10 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 22 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C91A2 Mature B-cell leukemia Burkitt-type, in relapse 10 10 10 Yes Yes Yes No


C91Z0 Other lymphoid leukemia not having achieved remission 10 10 10 Yes Yes Yes No
C91Z1 Other lymphoid leukemia, in remission 10 10 10 Yes Yes Yes No
C91Z2 Other lymphoid leukemia, in relapse 10 10 10 Yes Yes Yes No
C9200 Acute myeloblastic leukemia, not having achieved remission 8 8 8 Yes Yes Yes No
C9201 Acute myeloblastic leukemia, in remission 8 8 8 Yes Yes Yes No
C9202 Acute myeloblastic leukemia, in relapse 8 8 8 Yes Yes Yes No
C9210 Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission 9 9 9 15 Yes Yes Yes Yes
C9211 Chronic myeloid leukemia, BCR/ABL-positive, in remission 9 9 9 15 Yes Yes Yes Yes
C9212 Chronic myeloid leukemia, BCR/ABL-positive, in relapse 9 9 9 15 Yes Yes Yes Yes
C9220 Atypical chronic myeloid leukemia, BCR/ABL-negative, not having achieved remission 9 9 9 18 Yes Yes Yes Yes
C9221 Atypical chronic myeloid leukemia, BCR/ABL-negative, in remission 9 9 9 18 Yes Yes Yes Yes
C9222 Atypical chronic myeloid leukemia, BCR/ABL-negative, in relapse 9 9 9 18 Yes Yes Yes Yes
C9230 Myeloid sarcoma, not having achieved remission 9 9 9 18 Yes Yes Yes Yes
C9231 Myeloid sarcoma, in remission 9 9 9 18 Yes Yes Yes Yes
C9232 Myeloid sarcoma, in relapse 9 9 9 18 Yes Yes Yes Yes
C9240 Acute promyelocytic leukemia, not having achieved remission 8 8 8 Yes Yes Yes No
C9241 Acute promyelocytic leukemia, in remission 8 8 8 Yes Yes Yes No
C9242 Acute promyelocytic leukemia, in relapse 8 8 8 Yes Yes Yes No
C9250 Acute myelomonocytic leukemia, not having achieved remission 8 8 8 Yes Yes Yes No
C9251 Acute myelomonocytic leukemia, in remission 8 8 8 Yes Yes Yes No
C9252 Acute myelomonocytic leukemia, in relapse 8 8 8 Yes Yes Yes No
C9260 Acute myeloid leukemia with 11q23-abnormality not having achieved remission 8 8 8 Yes Yes Yes No
C9261 Acute myeloid leukemia with 11q23-abnormality in remission 8 8 8 Yes Yes Yes No
C9262 Acute myeloid leukemia with 11q23-abnormality in relapse 8 8 8 Yes Yes Yes No
C9290 Myeloid leukemia, unspecified, not having achieved remission 9 9 9 18 Yes Yes Yes Yes
C9291 Myeloid leukemia, unspecified in remission 9 9 9 18 Yes Yes Yes Yes
C9292 Myeloid leukemia, unspecified in relapse 9 9 9 18 Yes Yes Yes Yes
C92A0 Acute myeloid leukemia with multilineage dysplasia, not having achieved remission 8 8 8 Yes Yes Yes No
C92A1 Acute myeloid leukemia with multilineage dysplasia, in remission 8 8 8 Yes Yes Yes No
C92A2 Acute myeloid leukemia with multilineage dysplasia, in relapse 8 8 8 Yes Yes Yes No
C92Z0 Other myeloid leukemia not having achieved remission 9 9 9 18 Yes Yes Yes Yes
C92Z1 Other myeloid leukemia, in remission 9 9 9 18 Yes Yes Yes Yes
C92Z2 Other myeloid leukemia, in relapse 9 9 9 18 Yes Yes Yes Yes
C9300 Acute monoblastic/monocytic leukemia, not having achieved remission 8 8 8 Yes Yes Yes No
C9301 Acute monoblastic/monocytic leukemia, in remission 8 8 8 Yes Yes Yes No
C9302 Acute monoblastic/monocytic leukemia, in relapse 8 8 8 Yes Yes Yes No
C9310 Chronic myelomonocytic leukemia not having achieved remission 9 9 9 18 Yes Yes Yes Yes
C9311 Chronic myelomonocytic leukemia, in remission 9 9 9 18 Yes Yes Yes Yes
C9312 Chronic myelomonocytic leukemia, in relapse 9 9 9 18 Yes Yes Yes Yes
C9330 Juvenile myelomonocytic leukemia, not having achieved remission 9 9 9 18 Yes Yes Yes Yes
C9331 Juvenile myelomonocytic leukemia, in remission 9 9 9 18 Yes Yes Yes Yes
C9332 Juvenile myelomonocytic leukemia, in relapse 9 9 9 18 Yes Yes Yes Yes
C9390 Monocytic leukemia, unspecified, not having achieved remission 9 9 9 18 Yes Yes Yes Yes
C9391 Monocytic leukemia, unspecified in remission 9 9 9 18 Yes Yes Yes Yes
C9392 Monocytic leukemia, unspecified in relapse 9 9 9 18 Yes Yes Yes Yes
C93Z0 Other monocytic leukemia, not having achieved remission 9 9 9 18 Yes Yes Yes Yes
C93Z1 Other monocytic leukemia, in remission 9 9 9 18 Yes Yes Yes Yes
C93Z2 Other monocytic leukemia, in relapse 9 9 9 18 Yes Yes Yes Yes
C9400 Acute erythroid leukemia, not having achieved remission 8 8 8 Yes Yes Yes No
C9401 Acute erythroid leukemia, in remission 8 8 8 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 23 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

C9402 Acute erythroid leukemia, in relapse 8 8 8 Yes Yes Yes No


C9420 Acute megakaryoblastic leukemia not having achieved remission 8 8 8 Yes Yes Yes No
C9421 Acute megakaryoblastic leukemia, in remission 8 8 8 Yes Yes Yes No
C9422 Acute megakaryoblastic leukemia, in relapse 8 8 8 Yes Yes Yes No
C9430 Mast cell leukemia not having achieved remission 9 9 9 18 Yes Yes Yes Yes
C9431 Mast cell leukemia, in remission 9 9 9 18 Yes Yes Yes Yes
C9432 Mast cell leukemia, in relapse 9 9 9 18 Yes Yes Yes Yes
C9440 Acute panmyelosis with myelofibrosis not having achieved remission 8 8 8 Yes Yes Yes No
C9441 Acute panmyelosis with myelofibrosis, in remission 8 8 8 Yes Yes Yes No
C9442 Acute panmyelosis with myelofibrosis, in relapse 8 8 8 Yes Yes Yes No
C946 Myelodysplastic disease, not classified 48 48 48 Yes Yes Yes No
C9480 Other specified leukemias not having achieved remission 9 9 9 18 Yes Yes Yes Yes
C9481 Other specified leukemias, in remission 9 9 9 18 Yes Yes Yes Yes
C9482 Other specified leukemias, in relapse 9 9 9 18 Yes Yes Yes Yes
C9500 Acute leukemia of unspecified cell type not having achieved remission 8 8 8 Yes Yes Yes No
C9501 Acute leukemia of unspecified cell type, in remission 8 8 8 Yes Yes Yes No
C9502 Acute leukemia of unspecified cell type, in relapse 8 8 8 Yes Yes Yes No
C9510 Chronic leukemia of unspecified cell type not having achieved remission 10 10 10 Yes Yes Yes No
C9511 Chronic leukemia of unspecified cell type, in remission 10 10 10 Yes Yes Yes No
C9512 Chronic leukemia of unspecified cell type, in relapse 10 10 10 Yes Yes Yes No
C9590 Leukemia, unspecified not having achieved remission 10 10 10 Yes Yes Yes No
C9591 Leukemia, unspecified, in remission 10 10 10 Yes Yes Yes No
C9592 Leukemia, unspecified, in relapse 10 10 10 Yes Yes Yes No
C960 Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosis 10 10 10 Yes Yes Yes No
C9620 Malignant mast cell neoplasm, unspecified 10 10 10 18 Yes Yes Yes Yes
C9621 Aggressive systemic mastocytosis 10 10 10 18 Yes Yes Yes Yes
C9622 Mast cell sarcoma 10 10 10 18 Yes Yes Yes Yes
C9629 Other malignant mast cell neoplasm 10 10 10 18 Yes Yes Yes Yes
C964 Sarcoma of dendritic cells (accessory cells) 10 10 10 Yes Yes Yes No
C965 Multifocal and unisystemic Langerhans-cell histiocytosis 10 10 10 Yes Yes Yes No
C966 Unifocal Langerhans-cell histiocytosis 10 10 10 Yes Yes Yes No
C969 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified 10 10 10 Yes Yes Yes No
C96A Histiocytic sarcoma 10 10 10 Yes Yes Yes No
C96Z Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue 10 10 10 Yes Yes Yes No
D030 Melanoma in situ of lip 12 12 12 Yes Yes Yes No
D0310 Melanoma in situ of unspecified eyelid, including canthus 12 12 12 Yes Yes Yes No
D03111 Melanoma in situ of right upper eyelid, including canthus 12 12 12 Yes Yes Yes No
D03112 Melanoma in situ of right lower eyelid, including canthus 12 12 12 Yes Yes Yes No
D03121 Melanoma in situ of left upper eyelid, including canthus 12 12 12 Yes Yes Yes No
D03122 Melanoma in situ of left lower eyelid, including canthus 12 12 12 Yes Yes Yes No
D0320 Melanoma in situ of unspecified ear and external auricular canal 12 12 12 Yes Yes Yes No
D0321 Melanoma in situ of right ear and external auricular canal 12 12 12 Yes Yes Yes No
D0322 Melanoma in situ of left ear and external auricular canal 12 12 12 Yes Yes Yes No
D0330 Melanoma in situ of unspecified part of face 12 12 12 Yes Yes Yes No
D0339 Melanoma in situ of other parts of face 12 12 12 Yes Yes Yes No
D034 Melanoma in situ of scalp and neck 12 12 12 Yes Yes Yes No
D0351 Melanoma in situ of anal skin 12 12 12 Yes Yes Yes No
D0352 Melanoma in situ of breast (skin) (soft tissue) 12 12 12 Yes Yes Yes No
D0359 Melanoma in situ of other part of trunk 12 12 12 Yes Yes Yes No
D0360 Melanoma in situ of unspecified upper limb, including shoulder 12 12 12 Yes Yes Yes No
D0361 Melanoma in situ of right upper limb, including shoulder 12 12 12 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 24 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

D0362 Melanoma in situ of left upper limb, including shoulder 12 12 12 Yes Yes Yes No
D0370 Melanoma in situ of unspecified lower limb, including hip 12 12 12 Yes Yes Yes No
D0371 Melanoma in situ of right lower limb, including hip 12 12 12 Yes Yes Yes No
D0372 Melanoma in situ of left lower limb, including hip 12 12 12 Yes Yes Yes No
D038 Melanoma in situ of other sites 12 12 12 Yes Yes Yes No
D039 Melanoma in situ, unspecified 12 12 12 Yes Yes Yes No
D1802 Hemangioma of intracranial structures 12 12 12 Yes Yes Yes No
D320 Benign neoplasm of cerebral meninges 12 12 12 Yes Yes Yes No
D321 Benign neoplasm of spinal meninges 12 12 12 Yes Yes Yes No
D329 Benign neoplasm of meninges, unspecified 12 12 12 Yes Yes Yes No
D330 Benign neoplasm of brain, supratentorial 12 12 12 Yes Yes Yes No
D331 Benign neoplasm of brain, infratentorial 12 12 12 Yes Yes Yes No
D332 Benign neoplasm of brain, unspecified 12 12 12 Yes Yes Yes No
D333 Benign neoplasm of cranial nerves 12 12 12 Yes Yes Yes No
D334 Benign neoplasm of spinal cord 12 12 12 Yes Yes Yes No
D337 Benign neoplasm of other specified parts of central nervous system 12 12 12 Yes Yes Yes No
D339 Benign neoplasm of central nervous system, unspecified 12 12 12 Yes Yes Yes No
D352 Benign neoplasm of pituitary gland 12 12 12 Yes Yes Yes No
D353 Benign neoplasm of craniopharyngeal duct 12 12 12 Yes Yes Yes No
D354 Benign neoplasm of pineal gland 12 12 12 Yes Yes Yes No
D420 Neoplasm of uncertain behavior of cerebral meninges 12 12 12 Yes Yes Yes No
D421 Neoplasm of uncertain behavior of spinal meninges 12 12 12 Yes Yes Yes No
D429 Neoplasm of uncertain behavior of meninges, unspecified 12 12 12 Yes Yes Yes No
D430 Neoplasm of uncertain behavior of brain, supratentorial 12 12 12 Yes Yes Yes No
D431 Neoplasm of uncertain behavior of brain, infratentorial 12 12 12 Yes Yes Yes No
D432 Neoplasm of uncertain behavior of brain, unspecified 12 12 12 Yes Yes Yes No
D433 Neoplasm of uncertain behavior of cranial nerves 12 12 12 Yes Yes Yes No
D434 Neoplasm of uncertain behavior of spinal cord 12 12 12 Yes Yes Yes No
D438 Neoplasm of uncertain behavior of other specified parts of central nervous system 12 12 12 Yes Yes Yes No
D439 Neoplasm of uncertain behavior of central nervous system, unspecified 12 12 12 Yes Yes Yes No
D443 Neoplasm of uncertain behavior of pituitary gland 12 12 12 Yes Yes Yes No
D444 Neoplasm of uncertain behavior of craniopharyngeal duct 12 12 12 Yes Yes Yes No
D445 Neoplasm of uncertain behavior of pineal gland 12 12 12 Yes Yes Yes No
D446 Neoplasm of uncertain behavior of carotid body 12 12 12 Yes Yes Yes No
D447 Neoplasm of uncertain behavior of aortic body and other paraganglia 12 12 12 Yes Yes Yes No
D45 Polycythemia vera 48 48 48 Yes Yes Yes No
D460 Refractory anemia without ring sideroblasts, so stated 46 46 46 96 Yes Yes Yes Yes
D461 Refractory anemia with ring sideroblasts 46 46 46 96 Yes Yes Yes Yes
D4620 Refractory anemia with excess of blasts, unspecified 46 46 46 96 Yes Yes Yes Yes
D4621 Refractory anemia with excess of blasts 1 46 46 46 96 Yes Yes Yes Yes
D4622 Refractory anemia with excess of blasts 2 46 46 46 96 Yes Yes Yes Yes
D464 Refractory anemia, unspecified 46 46 46 96 Yes Yes Yes Yes
D469 Myelodysplastic syndrome, unspecified 46 46 46 96 Yes Yes Yes Yes
D46A Refractory cytopenia with multilineage dysplasia 46 46 46 96 Yes Yes Yes Yes
D46B Refractory cytopenia with multilineage dysplasia and ring sideroblasts 46 46 46 96 Yes Yes Yes Yes
D46C Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality 46 46 46 16 Yes Yes Yes Yes
D46Z Other myelodysplastic syndromes 46 46 46 96 Yes Yes Yes Yes
D471 Chronic myeloproliferative disease 48 48 48 Yes Yes Yes No
D473 Essential (hemorrhagic) thrombocythemia 48 48 48 Yes Yes Yes No
D474 Osteomyelofibrosis 46 46 46 96 Yes Yes Yes Yes
D479 Neoplasm of uncertain behavior of lymphoid, hematopoietic and related tissue, unspecified 48 48 48 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 25 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
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Year

D47Z1 Post-transplant lymphoproliferative disorder (PTLD) 48 48 48 Yes Yes Yes No


D47Z2 Castleman disease 48 48 48 Yes Yes Yes No
D47Z9 Other specified neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue 48 48 48 Yes Yes Yes No
D496 Neoplasm of unspecified behavior of brain 12 12 12 Yes Yes Yes No
D550 Anemia due to glucose-6-phosphate dehydrogenase [G6PD] deficiency 48 48 48 Yes Yes Yes No
D551 Anemia due to other disorders of glutathione metabolism 48 48 48 Yes Yes Yes No
D552 Anemia due to disorders of glycolytic enzymes 48 48 48 Yes Yes Yes No
D553 Anemia due to disorders of nucleotide metabolism 48 48 48 Yes Yes Yes No
D558 Other anemias due to enzyme disorders 48 48 48 Yes Yes Yes No
D559 Anemia due to enzyme disorder, unspecified 48 48 48 Yes Yes Yes No
D560 Alpha thalassemia 48 48 48 98 Yes Yes Yes Yes
D561 Beta thalassemia 48 48 48 98 Yes Yes Yes Yes
D562 Delta-beta thalassemia 48 48 48 Yes Yes Yes No
D564 Hereditary persistence of fetal hemoglobin [HPFH] 48 48 48 Yes Yes Yes No
D565 Hemoglobin E-beta thalassemia 48 48 48 98 Yes Yes Yes Yes
D568 Other thalassemias 48 48 48 Yes Yes Yes No
D5700 Hb-SS disease with crisis, unspecified 46 46 46 95 Yes Yes Yes Yes
D5701 Hb-SS disease with acute chest syndrome 46 46 46 95 Yes Yes Yes Yes
D5702 Hb-SS disease with splenic sequestration 46 46 46 95 Yes Yes Yes Yes
D5703 Hb-SS disease with cerebral vascular involvement 46 46 46 95 Yes Yes Yes Yes
D5709 Hb-SS disease with crisis with other specified complication 46 46 46 95 Yes Yes Yes Yes
D571 Sickle-cell disease without crisis 46 46 46 95 Yes Yes Yes Yes
D5720 Sickle-cell/Hb-C disease without crisis 46 46 46 98 Yes Yes Yes Yes
D57211 Sickle-cell/Hb-C disease with acute chest syndrome 46 46 46 98 Yes Yes Yes Yes
D57212 Sickle-cell/Hb-C disease with splenic sequestration 46 46 46 98 Yes Yes Yes Yes
D57213 Sickle-cell/Hb-C disease with cerebral vascular involvement 46 46 46 98 Yes Yes Yes Yes
D57218 Sickle-cell/Hb-C disease with crisis with other specified complication 46 46 46 98 Yes Yes Yes Yes
D57219 Sickle-cell/Hb-C disease with crisis, unspecified 46 46 46 98 Yes Yes Yes Yes
D573 Sickle-cell trait 48 48 48 Yes Yes Yes No
D5740 Sickle-cell thalassemia without crisis 46 46 46 98 Yes Yes Yes Yes
D57411 Sickle-cell thalassemia, unspecified, with acute chest syndrome 46 46 46 98 Yes Yes Yes Yes
D57412 Sickle-cell thalassemia, unspecified, with splenic sequestration 46 46 46 98 Yes Yes Yes Yes
D57413 Sickle-cell thalassemia, unspecified, with cerebral vascular involvement 46 46 46 98 Yes Yes Yes Yes
D57418 Sickle-cell thalassemia, unspecified, with crisis with other specified complication 46 46 46 98 Yes Yes Yes Yes
D57419 Sickle-cell thalassemia, unspecified, with crisis 46 46 46 98 Yes Yes Yes Yes
D5742 Sickle-cell thalassemia beta zero without crisis 46 46 46 95 Yes Yes Yes Yes
D57431 Sickle-cell thalassemia beta zero with acute chest syndrome 46 46 46 95 Yes Yes Yes Yes
D57432 Sickle-cell thalassemia beta zero with splenic sequestration 46 46 46 95 Yes Yes Yes Yes
D57433 Sickle-cell thalassemia beta zero with cerebral vascular involvement 46 46 46 95 Yes Yes Yes Yes
D57438 Sickle-cell thalassemia beta zero with crisis with other specified complication 46 46 46 95 Yes Yes Yes Yes
D57439 Sickle-cell thalassemia beta zero with crisis, unspecified 46 46 46 95 Yes Yes Yes Yes
D5744 Sickle-cell thalassemia beta plus without crisis 46 46 46 98 Yes Yes Yes Yes
D57451 Sickle-cell thalassemia beta plus with acute chest syndrome 46 46 46 98 Yes Yes Yes Yes
D57452 Sickle-cell thalassemia beta plus with splenic sequestration 46 46 46 98 Yes Yes Yes Yes
D57453 Sickle-cell thalassemia beta plus with cerebral vascular involvement 46 46 46 98 Yes Yes Yes Yes
D57458 Sickle-cell thalassemia beta plus with crisis with other specified complication 46 46 46 98 Yes Yes Yes Yes
D57459 Sickle-cell thalassemia beta plus with crisis, unspecified 46 46 46 98 Yes Yes Yes Yes
D5780 Other sickle-cell disorders without crisis 46 46 46 98 Yes Yes Yes Yes
D57811 Other sickle-cell disorders with acute chest syndrome 46 46 46 98 Yes Yes Yes Yes
D57812 Other sickle-cell disorders with splenic sequestration 46 46 46 98 Yes Yes Yes Yes
D57813 Other sickle-cell disorders with cerebral vascular involvement 46 46 46 98 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 26 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

D57818 Other sickle-cell disorders with crisis with other specified complication 46 46 46 98 Yes Yes Yes Yes
D57819 Other sickle-cell disorders with crisis, unspecified 46 46 46 98 Yes Yes Yes Yes
D580 Hereditary spherocytosis 48 48 48 Yes Yes Yes No
D581 Hereditary elliptocytosis 48 48 48 Yes Yes Yes No
D582 Other hemoglobinopathies 48 48 48 Yes Yes Yes No
D588 Other specified hereditary hemolytic anemias 48 48 48 Yes Yes Yes No
D589 Hereditary hemolytic anemia, unspecified 48 48 48 Yes Yes Yes No
D590 Drug-induced autoimmune hemolytic anemia 46 46 46 98 Yes Yes Yes Yes
D591 Other autoimmune hemolytic anemias 46 46 46 98 Yes Yes Yes Yes
D5910 Autoimmune hemolytic anemia, unspecified 46 46 46 98 Yes Yes Yes Yes
D5911 Warm autoimmune hemolytic anemia 46 46 46 98 Yes Yes Yes Yes
D5912 Cold autoimmune hemolytic anemia 46 46 46 98 Yes Yes Yes Yes
D5913 Mixed type autoimmune hemolytic anemia 46 46 46 98 Yes Yes Yes Yes
D5919 Other autoimmune hemolytic anemia 46 46 46 98 Yes Yes Yes Yes
D592 Drug-induced nonautoimmune hemolytic anemia 46 46 46 98 Yes Yes Yes Yes
D593 Hemolytic-uremic syndrome 46 46 46 98 Yes Yes Yes Yes
D594 Other nonautoimmune hemolytic anemias 46 46 46 98 Yes Yes Yes Yes
D595 Paroxysmal nocturnal hemoglobinuria [Marchiafava-Micheli] 46 46 46 98 Yes Yes Yes Yes
D596 Hemoglobinuria due to hemolysis from other external causes 46 46 46 98 Yes Yes Yes Yes
D598 Other acquired hemolytic anemias 46 46 46 98 Yes Yes Yes Yes
D599 Acquired hemolytic anemia, unspecified 46 46 46 98 Yes Yes Yes Yes
D600 Chronic acquired pure red cell aplasia 46 46 46 98 Yes Yes Yes Yes
D601 Transient acquired pure red cell aplasia 46 46 46 98 Yes Yes Yes Yes
D608 Other acquired pure red cell aplasias 46 46 46 98 Yes Yes Yes Yes
D609 Acquired pure red cell aplasia, unspecified 46 46 46 98 Yes Yes Yes Yes
D6101 Constitutional (pure) red blood cell aplasia 46 46 46 98 Yes Yes Yes Yes
D6109 Other constitutional aplastic anemia 46 46 46 98 Yes Yes Yes Yes
D611 Drug-induced aplastic anemia 46 46 46 98 Yes Yes Yes Yes
D612 Aplastic anemia due to other external agents 46 46 46 98 Yes Yes Yes Yes
D613 Idiopathic aplastic anemia 46 46 46 98 Yes Yes Yes Yes
D61810 Antineoplastic chemotherapy induced pancytopenia 47 47 47 Yes Yes Yes No
D61811 Other drug-induced pancytopenia 47 47 47 Yes Yes Yes No
D61818 Other pancytopenia 47 47 47 Yes Yes Yes No
D6182 Myelophthisis 46 46 46 98 Yes Yes Yes Yes
D6189 Other specified aplastic anemias and other bone marrow failure syndromes 46 46 46 98 Yes Yes Yes Yes
D619 Aplastic anemia, unspecified 46 46 46 98 Yes Yes Yes Yes
D640 Hereditary sideroblastic anemia 48 48 48 98 Yes Yes Yes Yes
D641 Secondary sideroblastic anemia due to disease 48 48 48 98 Yes Yes Yes Yes
D642 Secondary sideroblastic anemia due to drugs and toxins 48 48 48 98 Yes Yes Yes Yes
D643 Other sideroblastic anemias 48 48 48 98 Yes Yes Yes Yes
D65 Disseminated intravascular coagulation [defibrination syndrome] 48 48 48 Yes Yes Yes No
D66 Hereditary factor VIII deficiency 46 46 46 Yes Yes Yes No
D67 Hereditary factor IX deficiency 46 46 46 Yes Yes Yes No
D680 Von Willebrand's disease 48 48 48 Yes Yes Yes No
D681 Hereditary factor XI deficiency 48 48 48 Yes Yes Yes No
D682 Hereditary deficiency of other clotting factors 48 48 48 Yes Yes Yes No
D68311 Acquired hemophilia 48 48 48 Yes Yes Yes No
D68312 Antiphospholipid antibody with hemorrhagic disorder 48 48 48 Yes Yes Yes No
D68318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors 48 48 48 Yes Yes Yes No
D6832 Hemorrhagic disorder due to extrinsic circulating anticoagulants 48 48 48 Yes Yes Yes No
D684 Acquired coagulation factor deficiency 48 48 48 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 27 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

D6851 Activated protein C resistance 48 48 48 98 Yes Yes Yes Yes


D6852 Prothrombin gene mutation 48 48 48 98 Yes Yes Yes Yes
D6859 Other primary thrombophilia 48 48 48 98 Yes Yes Yes Yes
D6861 Antiphospholipid syndrome 48 48 48 98 Yes Yes Yes Yes
D6862 Lupus anticoagulant syndrome 48 48 48 98 Yes Yes Yes Yes
D6869 Other thrombophilia 48 48 48 98 Yes Yes Yes Yes
D688 Other specified coagulation defects 48 48 48 Yes Yes Yes No
D689 Coagulation defect, unspecified 48 48 48 Yes Yes Yes No
D690 Allergic purpura 48 48 48 Yes Yes Yes No
D691 Qualitative platelet defects 48 48 48 Yes Yes Yes No
D692 Other nonthrombocytopenic purpura 48 48 48 Yes Yes Yes No
D693 Immune thrombocytopenic purpura 48 48 48 Yes Yes Yes No
D6941 Evans syndrome 48 48 48 Yes Yes Yes No
D6942 Congenital and hereditary thrombocytopenia purpura 48 48 48 Yes Yes Yes No
D6949 Other primary thrombocytopenia 48 48 48 Yes Yes Yes No
D696 Thrombocytopenia, unspecified 48 48 48 Yes Yes Yes No
D698 Other specified hemorrhagic conditions 48 48 48 Yes Yes Yes No
D699 Hemorrhagic condition, unspecified 48 48 48 Yes Yes Yes No
D700 Congenital agranulocytosis 47 47 47 Yes Yes Yes No
D701 Agranulocytosis secondary to cancer chemotherapy 47 47 47 Yes Yes Yes No
D702 Other drug-induced agranulocytosis 47 47 47 Yes Yes Yes No
D703 Neutropenia due to infection 47 47 47 Yes Yes Yes No
D704 Cyclic neutropenia 47 47 47 Yes Yes Yes No
D708 Other neutropenia 47 47 47 Yes Yes Yes No
D709 Neutropenia, unspecified 47 47 47 Yes Yes Yes No
D71 Functional disorders of polymorphonuclear neutrophils 47 47 47 Yes Yes Yes No
D720 Genetic anomalies of leukocytes 47 47 47 Yes Yes Yes No
D7581 Myelofibrosis 46 46 46 96 Yes Yes Yes Yes
D7582 Heparin induced thrombocytopenia (HIT) 48 48 48 Yes Yes Yes No
D761 Hemophagocytic lymphohistiocytosis 47 47 47 Yes Yes Yes No
D762 Hemophagocytic syndrome, infection-associated 47 47 47 Yes Yes Yes No
D763 Other histiocytosis syndromes 47 47 47 Yes Yes Yes No
D800 Hereditary hypogammaglobulinemia 47 47 47 97 Yes Yes Yes Yes
D801 Nonfamilial hypogammaglobulinemia 47 47 47 97 Yes Yes Yes Yes
D802 Selective deficiency of immunoglobulin A [IgA] 47 47 47 97 Yes Yes Yes Yes
D803 Selective deficiency of immunoglobulin G [IgG] subclasses 47 47 47 97 Yes Yes Yes Yes
D804 Selective deficiency of immunoglobulin M [IgM] 47 47 47 97 Yes Yes Yes Yes
D805 Immunodeficiency with increased immunoglobulin M [IgM] 47 47 47 97 Yes Yes Yes Yes
D806 Antibody deficiency with near-normal immunoglobulins or with hyperimmunoglobulinemia 47 47 47 97 Yes Yes Yes Yes
D807 Transient hypogammaglobulinemia of infancy 47 47 47 97 Yes Yes Yes Yes
D808 Other immunodeficiencies with predominantly antibody defects 47 47 47 97 Yes Yes Yes Yes
D809 Immunodeficiency with predominantly antibody defects, unspecified 47 47 47 97 Yes Yes Yes Yes
D810 Severe combined immunodeficiency [SCID] with reticular dysgenesis 47 47 47 97 Yes Yes Yes Yes
D811 Severe combined immunodeficiency [SCID] with low T- and B-cell numbers 47 47 47 97 Yes Yes Yes Yes
D812 Severe combined immunodeficiency [SCID] with low or normal B-cell numbers 47 47 47 97 Yes Yes Yes Yes
D8130 Adenosine deaminase deficiency, unspecified 47 47 47 97 Yes Yes Yes Yes
D8131 Severe combined immunodeficiency due to adenosine deaminase deficiency 47 47 47 97 Yes Yes Yes Yes
D8132 Adenosine deaminase 2 deficiency 47 47 47 97 Yes Yes Yes Yes
D8139 Other adenosine deaminase deficiency 47 47 47 97 Yes Yes Yes Yes
D814 Nezelof's syndrome 47 47 47 97 Yes Yes Yes Yes
D815 Purine nucleoside phosphorylase [PNP] deficiency 47 47 47 97 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 28 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

D816 Major histocompatibility complex class I deficiency 47 47 47 97 Yes Yes Yes Yes
D817 Major histocompatibility complex class II deficiency 47 47 47 97 Yes Yes Yes Yes
D8189 Other combined immunodeficiencies 47 47 47 97 Yes Yes Yes Yes
D819 Combined immunodeficiency, unspecified 47 47 47 97 Yes Yes Yes Yes
D820 Wiskott-Aldrich syndrome 47 47 47 97 Yes Yes Yes Yes
D821 Di George's syndrome 47 47 47 97 Yes Yes Yes Yes
D822 Immunodeficiency with short-limbed stature 47 47 47 97 Yes Yes Yes Yes
D823 Immunodeficiency following hereditary defective response to Epstein-Barr virus 47 47 47 97 Yes Yes Yes Yes
D824 Hyperimmunoglobulin E [IgE] syndrome 47 47 47 97 Yes Yes Yes Yes
D828 Immunodeficiency associated with other specified major defects 47 47 47 97 Yes Yes Yes Yes
D829 Immunodeficiency associated with major defect, unspecified 47 47 47 97 Yes Yes Yes Yes
D830 Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function 47 47 47 97 Yes Yes Yes Yes

D831 Common variable immunodeficiency with predominant immunoregulatory T-cell disorders 47 47 47 97 Yes Yes Yes Yes
D832 Common variable immunodeficiency with autoantibodies to B- or T-cells 47 47 47 97 Yes Yes Yes Yes
D838 Other common variable immunodeficiencies 47 47 47 97 Yes Yes Yes Yes
D839 Common variable immunodeficiency, unspecified 47 47 47 97 Yes Yes Yes Yes
D840 Lymphocyte function antigen-1 [LFA-1] defect 47 47 47 97 Yes Yes Yes Yes
D841 Defects in the complement system 23 23 23 40 Yes Yes Yes Yes
D848 Other specified immunodeficiencies 47 47 47 97 Yes Yes Yes Yes
D8481 Immunodeficiency due to conditions classified elsewhere 47 47 47 97 Yes Yes Yes Yes
D84821 Immunodeficiency due to drugs 47 47 47 97 Yes Yes Yes Yes
D84822 Immunodeficiency due to external causes 47 47 47 97 Yes Yes Yes Yes
D8489 Other immunodeficiencies 47 47 47 97 Yes Yes Yes Yes
D849 Immunodeficiency, unspecified 47 47 47 97 Yes Yes Yes Yes
D860 Sarcoidosis of lung 112 112 112 Yes Yes Yes No
D862 Sarcoidosis of lung with sarcoidosis of lymph nodes 112 112 112 Yes Yes Yes No
D8682 Multiple cranial nerve palsies in sarcoidosis 75 75 75 159 Yes Yes Yes Yes
D8684 Sarcoid pyelonephritis 141 Yes No No No
D891 Cryoglobulinemia 23 23 23 Yes Yes Yes No
D893 Immune reconstitution syndrome 47 47 47 97 Yes Yes Yes Yes
D8940 Mast cell activation, unspecified 47 47 47 97 Yes Yes Yes Yes
D8941 Monoclonal mast cell activation syndrome 47 47 47 97 Yes Yes Yes Yes
D8942 Idiopathic mast cell activation syndrome 47 47 47 97 Yes Yes Yes Yes
D8943 Secondary mast cell activation 47 47 47 97 Yes Yes Yes Yes
D8949 Other mast cell activation disorder 47 47 47 97 Yes Yes Yes Yes
D89810 Acute graft-versus-host disease 47 47 47 396 Yes Yes Yes Yes
D89811 Chronic graft-versus-host disease 47 47 47 396 Yes Yes Yes Yes
D89812 Acute on chronic graft-versus-host disease 47 47 47 396 Yes Yes Yes Yes
D89813 Graft-versus-host disease, unspecified 47 47 47 396 Yes Yes Yes Yes
D8982 Autoimmune lymphoproliferative syndrome [ALPS] 47 47 47 97 Yes Yes Yes Yes
D8989 Other specified disorders involving the immune mechanism, not elsewhere classified 47 47 47 97 Yes Yes Yes Yes
D899 Disorder involving the immune mechanism, unspecified 47 47 47 97 Yes Yes Yes Yes
E000 Congenital iodine-deficiency syndrome, neurological type 42 No No No Yes
E001 Congenital iodine-deficiency syndrome, myxedematous type 42 No No No Yes
E002 Congenital iodine-deficiency syndrome, mixed type 42 No No No Yes
E009 Congenital iodine-deficiency syndrome, unspecified 42 No No No Yes
E010 Iodine-deficiency related diffuse (endemic) goiter 42 No No No Yes
E011 Iodine-deficiency related multinodular (endemic) goiter 42 No No No Yes
E012 Iodine-deficiency related (endemic) goiter, unspecified 42 No No No Yes
E018 Other iodine-deficiency related thyroid disorders and allied conditions 42 No No No Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 29 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E02 Subclinical iodine-deficiency hypothyroidism 42 No No No Yes


E030 Congenital hypothyroidism with diffuse goiter 42 No No No Yes
E031 Congenital hypothyroidism without goiter 42 No No No Yes
E032 Hypothyroidism due to medicaments and other exogenous substances 42 No No No Yes
E033 Postinfectious hypothyroidism 42 No No No Yes
E034 Atrophy of thyroid (acquired) 42 No No No Yes
E035 Myxedema coma 23 23 23 42 Yes Yes Yes Yes
E038 Other specified hypothyroidism 42 No No No Yes
E039 Hypothyroidism, unspecified 42 No No No Yes
E040 Nontoxic diffuse goiter 42 No No No Yes
E041 Nontoxic single thyroid nodule 42 No No No Yes
E042 Nontoxic multinodular goiter 42 No No No Yes
E048 Other specified nontoxic goiter 42 No No No Yes
E049 Nontoxic goiter, unspecified 42 No No No Yes
E0500 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm 42 No No No Yes
E0501 Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm 42 No No No Yes
E0510 Thyrotoxicosis with toxic single thyroid nodule without thyrotoxic crisis or storm 42 No No No Yes
E0511 Thyrotoxicosis with toxic single thyroid nodule with thyrotoxic crisis or storm 42 No No No Yes
E0520 Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis or storm 42 No No No Yes
E0521 Thyrotoxicosis with toxic multinodular goiter with thyrotoxic crisis or storm 42 No No No Yes
E0530 Thyrotoxicosis from ectopic thyroid tissue without thyrotoxic crisis or storm 42 No No No Yes
E0531 Thyrotoxicosis from ectopic thyroid tissue with thyrotoxic crisis or storm 42 No No No Yes
E0540 Thyrotoxicosis factitia without thyrotoxic crisis or storm 42 No No No Yes
E0541 Thyrotoxicosis factitia with thyrotoxic crisis or storm 42 No No No Yes
E0580 Other thyrotoxicosis without thyrotoxic crisis or storm 42 No No No Yes
E0581 Other thyrotoxicosis with thyrotoxic crisis or storm 42 No No No Yes
E0590 Thyrotoxicosis, unspecified without thyrotoxic crisis or storm 42 No No No Yes
E0591 Thyrotoxicosis, unspecified with thyrotoxic crisis or storm 42 No No No Yes
E060 Acute thyroiditis 42 No No No Yes
E061 Subacute thyroiditis 42 No No No Yes
E062 Chronic thyroiditis with transient thyrotoxicosis 42 No No No Yes
E063 Autoimmune thyroiditis 42 No No No Yes
E064 Drug-induced thyroiditis 42 No No No Yes
E065 Other chronic thyroiditis 42 No No No Yes
E069 Thyroiditis, unspecified 42 No No No Yes
E070 Hypersecretion of calcitonin 42 No No No Yes
E071 Dyshormogenetic goiter 42 No No No Yes
E0789 Other specified disorders of thyroid 42 No No No Yes
E079 Disorder of thyroid, unspecified 42 No No No Yes
E0800 Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic 17 17 17 30 Yes Yes Yes Yes
hyperglycemic-hyperosmolar coma (NKHHC)
E0801 Diabetes mellitus due to underlying condition with hyperosmolarity with coma 17 17 17 30 Yes Yes Yes Yes
E0810 Diabetes mellitus due to underlying condition with ketoacidosis without coma 17 17 17 30 Yes Yes Yes Yes
E0811 Diabetes mellitus due to underlying condition with ketoacidosis with coma 17 17 17 30 Yes Yes Yes Yes
E0821 Diabetes mellitus due to underlying condition with diabetic nephropathy 18 18 18 30 Yes Yes Yes Yes
E0821 Diabetes mellitus due to underlying condition with diabetic nephropathy 141 Yes -- -- --
E0822 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease 18 18 18 30 Yes Yes Yes Yes
E0822 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease 139 Yes -- -- --
E0829 Diabetes mellitus due to underlying condition with other diabetic kidney complication 18 18 18 30 Yes Yes Yes Yes
E0829 Diabetes mellitus due to underlying condition with other diabetic kidney complication 141 Yes -- -- --

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 30 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E08311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema
E08311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular 241 -- -- -- Yes
edema
E08319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema
E08319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular 241 -- -- -- Yes
edema
E083211 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, right eye
E083211 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, right eye
E083212 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, left eye
E083212 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, left eye
E083213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, bilateral
E083213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, bilateral
E083219 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, unspecified eye
E083219 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, unspecified eye
E083291 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
without macular edema, right eye
E083291 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy 241 -- -- -- Yes
without macular edema, right eye
E083292 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
without macular edema, left eye
E083292 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy 241 -- -- -- Yes
without macular edema, left eye
E083293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
without macular edema, bilateral
E083293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy 241 -- -- -- Yes
without macular edema, bilateral
E083299 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
without macular edema, unspecified eye
E083299 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy 241 -- -- -- Yes
without macular edema, unspecified eye
E083311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
with macular edema, right eye
E083311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy 241 -- -- -- Yes
with macular edema, right eye
E083312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
with macular edema, left eye
E083312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy 241 -- -- -- Yes
with macular edema, left eye
E083313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
with macular edema, bilateral

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 31 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E083313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy 241 -- -- -- Yes
with macular edema, bilateral
E083319 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
with macular edema, unspecified eye
E083319 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy 241 -- -- -- Yes
with macular edema, unspecified eye
E083391 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
without macular edema, right eye
E083391 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy 241 -- -- -- Yes
without macular edema, right eye
E083392 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
without macular edema, left eye
E083392 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy 241 -- -- -- Yes
without macular edema, left eye
E083393 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
without macular edema, bilateral
E083393 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy 241 -- -- -- Yes
without macular edema, bilateral
E083399 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
without macular edema, unspecified eye
E083399 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy 241 -- -- -- Yes
without macular edema, unspecified eye
E083411 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, right eye
E083411 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, right eye
E083412 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, left eye
E083412 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, left eye
E083413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, bilateral
E083413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, bilateral
E083419 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, unspecified eye
E083419 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, unspecified eye
E083491 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
without macular edema, right eye
E083491 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy 241 -- -- -- Yes
without macular edema, right eye
E083492 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
without macular edema, left eye
E083492 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy 241 -- -- -- Yes
without macular edema, left eye
E083493 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
without macular edema, bilateral
E083493 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy 241 -- -- -- Yes
without macular edema, bilateral

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 32 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E083499 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
without macular edema, unspecified eye
E083499 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy 241 -- -- -- Yes
without macular edema, unspecified eye
E083511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, right eye
E083511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular 122 122 122 241 Yes Yes Yes Yes
edema, right eye
E083512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, left eye
E083512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular 122 122 122 241 Yes Yes Yes Yes
edema, left eye
E083513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, bilateral
E083513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular 122 122 122 241 Yes Yes Yes Yes
edema, bilateral
E083519 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, unspecified eye
E083519 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular 122 122 122 241 Yes Yes Yes Yes
edema, unspecified eye
E083521 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment involving the macula, right eye
E083521 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment involving the macula, right eye
E083522 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment involving the macula, left eye
E083522 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment involving the macula, left eye
E083523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment involving the macula, bilateral
E083523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment involving the macula, bilateral
E083529 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment involving the macula, unspecified eye
E083529 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment involving the macula, unspecified eye
E083531 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment not involving the macula, right eye
E083531 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment not involving the macula, right eye
E083532 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment not involving the macula, left eye
E083532 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment not involving the macula, left eye
E083533 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment not involving the macula, bilateral
E083533 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment not involving the macula, bilateral
E083539 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment not involving the macula, unspecified eye

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 33 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E083539 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment not involving the macula, unspecified eye
E083541 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined 18 18 18 30 Yes Yes Yes Yes
traction retinal detachment and rhegmatogenous retinal detachment, right eye
E083541 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined 122 122 122 241 Yes Yes Yes Yes
traction retinal detachment and rhegmatogenous retinal detachment, right eye
E083542 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined 18 18 18 30 Yes Yes Yes Yes
traction retinal detachment and rhegmatogenous retinal detachment, left eye
E083542 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined 122 122 122 241 Yes Yes Yes Yes
traction retinal detachment and rhegmatogenous retinal detachment, left eye
E083543 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined 18 18 18 30 Yes Yes Yes Yes
traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E083543 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined 122 122 122 241 Yes Yes Yes Yes
traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E083549 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined 18 18 18 30 Yes Yes Yes Yes
traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye
E083549 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined 122 122 122 241 Yes Yes Yes Yes
traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye
E083551 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye 18 18 18 30 Yes Yes Yes Yes
E083551 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye 122 122 122 241 Yes Yes Yes Yes
E083552 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye 18 18 18 30 Yes Yes Yes Yes
E083552 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye 122 122 122 241 Yes Yes Yes Yes
E083553 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral 18 18 18 30 Yes Yes Yes Yes
E083553 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral 122 122 122 241 Yes Yes Yes Yes
E083559 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, 18 18 18 30 Yes Yes Yes Yes
unspecified eye
E083559 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, 122 122 122 241 Yes Yes Yes Yes
unspecified eye
E083591 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, right eye
E083591 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular 122 122 122 241 Yes Yes Yes Yes
edema, right eye
E083592 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, left eye
E083592 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular 122 122 122 241 Yes Yes Yes Yes
edema, left eye
E083593 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, bilateral
E083593 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular 122 122 122 241 Yes Yes Yes Yes
edema, bilateral
E083599 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, unspecified eye
E083599 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular 122 122 122 241 Yes Yes Yes Yes
edema, unspecified eye
E0836 Diabetes mellitus due to underlying condition with diabetic cataract 18 18 18 30 Yes Yes Yes Yes
E0837X1 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following 18 18 18 30 Yes Yes Yes Yes
treatment, right eye
E0837X2 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following 18 18 18 30 Yes Yes Yes Yes
treatment, left eye
E0837X3 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following 18 18 18 30 Yes Yes Yes Yes
treatment, bilateral

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 34 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E0837X9 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following 18 18 18 30 Yes Yes Yes Yes
treatment, unspecified eye
E0839 Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication 18 18 18 30 Yes Yes Yes Yes
E0840 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified 18 18 18 30 Yes Yes Yes Yes
E0840 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified 75 Yes -- -- --
E0841 Diabetes mellitus due to underlying condition with diabetic mononeuropathy 18 18 18 30 Yes Yes Yes Yes
E0841 Diabetes mellitus due to underlying condition with diabetic mononeuropathy 75 Yes -- -- --
E0842 Diabetes mellitus due to underlying condition with diabetic polyneuropathy 18 18 18 30 Yes Yes Yes Yes
E0842 Diabetes mellitus due to underlying condition with diabetic polyneuropathy 75 Yes -- -- --
E0843 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy 18 18 18 30 Yes Yes Yes Yes
E0843 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy 75 Yes -- -- --
E0844 Diabetes mellitus due to underlying condition with diabetic amyotrophy 18 18 18 30 Yes Yes Yes Yes
E0844 Diabetes mellitus due to underlying condition with diabetic amyotrophy 75 Yes -- -- --
E0849 Diabetes mellitus due to underlying condition with other diabetic neurological complication 18 18 18 30 Yes Yes Yes Yes
E0849 Diabetes mellitus due to underlying condition with other diabetic neurological complication 75 Yes -- -- --
E0851 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene 18 18 18 30 Yes Yes Yes Yes
E0851 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene 108 108 108 216 Yes Yes Yes Yes
E0852 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene 18 18 18 30 Yes Yes Yes Yes
E0852 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene 106 106 106 216 Yes Yes Yes Yes
E0852 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene 108 108 108 Yes Yes Yes --
E0859 Diabetes mellitus due to underlying condition with other circulatory complications 18 18 18 30 Yes Yes Yes Yes
E08610 Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy 18 18 18 30 Yes Yes Yes Yes
E08618 Diabetes mellitus due to underlying condition with other diabetic arthropathy 18 18 18 30 Yes Yes Yes Yes
E08620 Diabetes mellitus due to underlying condition with diabetic dermatitis 18 18 18 30 Yes Yes Yes Yes
E08621 Diabetes mellitus due to underlying condition with foot ulcer 18 18 18 30 Yes Yes Yes Yes
E08621 Diabetes mellitus due to underlying condition with foot ulcer 161 161 161 311 Yes Yes Yes Yes
E08622 Diabetes mellitus due to underlying condition with other skin ulcer 18 18 18 30 Yes Yes Yes Yes
E08622 Diabetes mellitus due to underlying condition with other skin ulcer 161 161 161 311 Yes Yes Yes Yes
E08628 Diabetes mellitus due to underlying condition with other skin complications 18 18 18 30 Yes Yes Yes Yes
E08630 Diabetes mellitus due to underlying condition with periodontal disease 18 18 18 30 Yes Yes Yes Yes
E08638 Diabetes mellitus due to underlying condition with other oral complications 18 18 18 30 Yes Yes Yes Yes
E08641 Diabetes mellitus due to underlying condition with hypoglycemia with coma 17 17 17 30 Yes Yes Yes Yes
E08649 Diabetes mellitus due to underlying condition with hypoglycemia without coma 18 18 18 30 Yes Yes Yes Yes
E0865 Diabetes mellitus due to underlying condition with hyperglycemia 18 18 18 30 Yes Yes Yes Yes
E0869 Diabetes mellitus due to underlying condition with other specified complication 18 18 18 30 Yes Yes Yes Yes
E088 Diabetes mellitus due to underlying condition with unspecified complications 18 18 18 30 Yes Yes Yes Yes
E089 Diabetes mellitus due to underlying condition without complications 19 19 19 31 Yes Yes Yes Yes
E0900 Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic- 17 17 17 30 Yes Yes Yes Yes
hyperosmolar coma (NKHHC)
E0901 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma 17 17 17 30 Yes Yes Yes Yes
E0910 Drug or chemical induced diabetes mellitus with ketoacidosis without coma 17 17 17 30 Yes Yes Yes Yes
E0911 Drug or chemical induced diabetes mellitus with ketoacidosis with coma 17 17 17 30 Yes Yes Yes Yes
E0921 Drug or chemical induced diabetes mellitus with diabetic nephropathy 18 18 18 30 Yes Yes Yes Yes
E0921 Drug or chemical induced diabetes mellitus with diabetic nephropathy 141 Yes -- -- --
E0922 Drug or chemical induced diabetes mellitus with diabetic chronic kidney disease 18 18 18 30 Yes Yes Yes Yes
E0922 Drug or chemical induced diabetes mellitus with diabetic chronic kidney disease 139 Yes -- -- --
E0929 Drug or chemical induced diabetes mellitus with other diabetic kidney complication 18 18 18 30 Yes Yes Yes Yes
E0929 Drug or chemical induced diabetes mellitus with other diabetic kidney complication 141 Yes -- -- --
E09311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 35 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E09311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular 241 -- -- -- Yes
edema
E09319 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema
E09319 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular 241 -- -- -- Yes
edema
E093211 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, right eye
E093211 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, right eye
E093212 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, left eye
E093212 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, left eye
E093213 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, bilateral
E093213 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, bilateral
E093219 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, unspecified eye
E093219 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, unspecified eye
E093291 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without 18 18 18 30 Yes Yes Yes Yes
macular edema, right eye
E093291 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without 241 -- -- -- Yes
macular edema, right eye
E093292 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without 18 18 18 30 Yes Yes Yes Yes
macular edema, left eye
E093292 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without 241 -- -- -- Yes
macular edema, left eye
E093293 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without 18 18 18 30 Yes Yes Yes Yes
macular edema, bilateral
E093293 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without 241 -- -- -- Yes
macular edema, bilateral
E093299 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without 18 18 18 30 Yes Yes Yes Yes
macular edema, unspecified eye
E093299 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without 241 -- -- -- Yes
macular edema, unspecified eye
E093311 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, right eye
E093311 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, right eye
E093312 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, left eye
E093312 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, left eye
E093313 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, bilateral
E093313 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, bilateral

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 36 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E093319 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, unspecified eye
E093319 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, unspecified eye
E093391 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
without macular edema, right eye
E093391 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy 241 -- -- -- Yes
without macular edema, right eye
E093392 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
without macular edema, left eye
E093392 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy 241 -- -- -- Yes
without macular edema, left eye
E093393 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
without macular edema, bilateral
E093393 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy 241 -- -- -- Yes
without macular edema, bilateral
E093399 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy 18 18 18 30 Yes Yes Yes Yes
without macular edema, unspecified eye
E093399 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy 241 -- -- -- Yes
without macular edema, unspecified eye
E093411 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, right eye
E093411 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, right eye
E093412 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, left eye
E093412 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, left eye
E093413 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, bilateral
E093413 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, bilateral
E093419 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with 18 18 18 30 Yes Yes Yes Yes
macular edema, unspecified eye
E093419 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with 241 -- -- -- Yes
macular edema, unspecified eye
E093491 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without 18 18 18 30 Yes Yes Yes Yes
macular edema, right eye
E093491 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without 241 -- -- -- Yes
macular edema, right eye
E093492 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without 18 18 18 30 Yes Yes Yes Yes
macular edema, left eye
E093492 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without 241 -- -- -- Yes
macular edema, left eye
E093493 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without 18 18 18 30 Yes Yes Yes Yes
macular edema, bilateral
E093493 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without 241 -- -- -- Yes
macular edema, bilateral
E093499 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without 18 18 18 30 Yes Yes Yes Yes
macular edema, unspecified eye

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 37 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E093499 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without 241 -- -- -- Yes
macular edema, unspecified eye
E093511 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, right eye
E093511 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular 122 122 122 241 Yes Yes Yes Yes
edema, right eye
E093512 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, left eye
E093512 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular 122 122 122 241 Yes Yes Yes Yes
edema, left eye
E093513 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, bilateral
E093513 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular 122 122 122 241 Yes Yes Yes Yes
edema, bilateral
E093519 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, unspecified eye
E093519 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular 122 122 122 241 Yes Yes Yes Yes
edema, unspecified eye
E093521 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment involving the macula, right eye
E093521 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment involving the macula, right eye
E093522 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment involving the macula, left eye
E093522 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment involving the macula, left eye
E093523 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment involving the macula, bilateral
E093523 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment involving the macula, bilateral
E093529 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment involving the macula, unspecified eye
E093529 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment involving the macula, unspecified eye
E093531 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment not involving the macula, right eye
E093531 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment not involving the macula, right eye
E093532 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment not involving the macula, left eye
E093532 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment not involving the macula, left eye
E093533 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment not involving the macula, bilateral
E093533 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment not involving the macula, bilateral
E093539 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment not involving the macula, unspecified eye
E093539 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment not involving the macula, unspecified eye

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 38 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E093541 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined 18 18 18 30 Yes Yes Yes Yes
traction retinal detachment and rhegmatogenous retinal detachment, right eye
E093541 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined 122 122 122 241 Yes Yes Yes Yes
traction retinal detachment and rhegmatogenous retinal detachment, right eye
E093542 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined 18 18 18 30 Yes Yes Yes Yes
traction retinal detachment and rhegmatogenous retinal detachment, left eye
E093542 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined 122 122 122 241 Yes Yes Yes Yes
traction retinal detachment and rhegmatogenous retinal detachment, left eye
E093543 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined 18 18 18 30 Yes Yes Yes Yes
traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E093543 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined 122 122 122 241 Yes Yes Yes Yes
traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E093549 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined 18 18 18 30 Yes Yes Yes Yes
traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye
E093549 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined 122 122 122 241 Yes Yes Yes Yes
traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye
E093551 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right eye 18 18 18 30 Yes Yes Yes Yes
E093551 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right eye 122 122 122 241 Yes Yes Yes Yes
E093552 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, left eye 18 18 18 30 Yes Yes Yes Yes
E093552 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, left eye 122 122 122 241 Yes Yes Yes Yes
E093553 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, bilateral 18 18 18 30 Yes Yes Yes Yes
E093553 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, bilateral 122 122 122 241 Yes Yes Yes Yes
E093559 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, unspecified 18 18 18 30 Yes Yes Yes Yes
eye
E093559 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, unspecified 122 122 122 241 Yes Yes Yes Yes
eye
E093591 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, right eye
E093591 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular 122 122 122 241 Yes Yes Yes Yes
edema, right eye
E093592 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, left eye
E093592 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular 122 122 122 241 Yes Yes Yes Yes
edema, left eye
E093593 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, bilateral
E093593 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular 122 122 122 241 Yes Yes Yes Yes
edema, bilateral
E093599 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, unspecified eye
E093599 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular 122 122 122 241 Yes Yes Yes Yes
edema, unspecified eye
E0936 Drug or chemical induced diabetes mellitus with diabetic cataract 18 18 18 30 Yes Yes Yes Yes
E0937X1 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following 18 18 18 30 Yes Yes Yes Yes
treatment, right eye
E0937X2 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following 18 18 18 30 Yes Yes Yes Yes
treatment, left eye
E0937X3 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following 18 18 18 30 Yes Yes Yes Yes
treatment, bilateral
E0937X9 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following 18 18 18 30 Yes Yes Yes Yes
treatment, unspecified eye

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 39 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E0939 Drug or chemical induced diabetes mellitus with other diabetic ophthalmic complication 18 18 18 30 Yes Yes Yes Yes
E0940 Drug or chemical induced diabetes mellitus with neurological complications with diabetic 18 18 18 30 Yes Yes Yes Yes
neuropathy, unspecified
E0940 Drug or chemical induced diabetes mellitus with neurological complications with diabetic 75 Yes -- -- --
neuropathy, unspecified
E0941 Drug or chemical induced diabetes mellitus with neurological complications with diabetic 18 18 18 30 Yes Yes Yes Yes
mononeuropathy
E0941 Drug or chemical induced diabetes mellitus with neurological complications with diabetic 75 Yes -- -- --
mononeuropathy
E0942 Drug or chemical induced diabetes mellitus with neurological complications with diabetic 18 18 18 30 Yes Yes Yes Yes
polyneuropathy
E0942 Drug or chemical induced diabetes mellitus with neurological complications with diabetic 75 Yes -- -- --
polyneuropathy
E0943 Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic 18 18 18 30 Yes Yes Yes Yes
(poly)neuropathy
E0943 Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic 75 Yes -- -- --
(poly)neuropathy
E0944 Drug or chemical induced diabetes mellitus with neurological complications with diabetic 18 18 18 30 Yes Yes Yes Yes
amyotrophy
E0944 Drug or chemical induced diabetes mellitus with neurological complications with diabetic 75 Yes -- -- --
amyotrophy
E0949 Drug or chemical induced diabetes mellitus with neurological complications with other diabetic 18 18 18 30 Yes Yes Yes Yes
neurological complication
E0949 Drug or chemical induced diabetes mellitus with neurological complications with other diabetic 75 Yes -- -- --
neurological complication
E0951 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene 18 18 18 30 Yes Yes Yes Yes
E0951 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene 108 108 108 216 Yes Yes Yes Yes
E0952 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene 18 18 18 30 Yes Yes Yes Yes
E0952 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene 106 106 106 216 Yes Yes Yes Yes
E0952 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene 108 108 108 Yes Yes Yes --
E0959 Drug or chemical induced diabetes mellitus with other circulatory complications 18 18 18 30 Yes Yes Yes Yes
E09610 Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathy 18 18 18 30 Yes Yes Yes Yes
E09618 Drug or chemical induced diabetes mellitus with other diabetic arthropathy 18 18 18 30 Yes Yes Yes Yes
E09620 Drug or chemical induced diabetes mellitus with diabetic dermatitis 18 18 18 30 Yes Yes Yes Yes
E09621 Drug or chemical induced diabetes mellitus with foot ulcer 18 18 18 30 Yes Yes Yes Yes
E09621 Drug or chemical induced diabetes mellitus with foot ulcer 161 161 161 311 Yes Yes Yes Yes
E09622 Drug or chemical induced diabetes mellitus with other skin ulcer 18 18 18 30 Yes Yes Yes Yes
E09622 Drug or chemical induced diabetes mellitus with other skin ulcer 161 161 161 311 Yes Yes Yes Yes
E09628 Drug or chemical induced diabetes mellitus with other skin complications 18 18 18 30 Yes Yes Yes Yes
E09630 Drug or chemical induced diabetes mellitus with periodontal disease 18 18 18 30 Yes Yes Yes Yes
E09638 Drug or chemical induced diabetes mellitus with other oral complications 18 18 18 30 Yes Yes Yes Yes
E09641 Drug or chemical induced diabetes mellitus with hypoglycemia with coma 17 17 17 30 Yes Yes Yes Yes
E09649 Drug or chemical induced diabetes mellitus with hypoglycemia without coma 18 18 18 30 Yes Yes Yes Yes
E0965 Drug or chemical induced diabetes mellitus with hyperglycemia 18 18 18 30 Yes Yes Yes Yes
E0969 Drug or chemical induced diabetes mellitus with other specified complication 18 18 18 30 Yes Yes Yes Yes
E098 Drug or chemical induced diabetes mellitus with unspecified complications 18 18 18 30 Yes Yes Yes Yes
E099 Drug or chemical induced diabetes mellitus without complications 19 19 19 31 Yes Yes Yes Yes
E1010 Type 1 diabetes mellitus with ketoacidosis without coma 17 17 17 30 Yes Yes Yes Yes
E1011 Type 1 diabetes mellitus with ketoacidosis with coma 17 17 17 30 Yes Yes Yes Yes
E1021 Type 1 diabetes mellitus with diabetic nephropathy 18 18 18 30 Yes Yes Yes Yes
E1021 Type 1 diabetes mellitus with diabetic nephropathy 141 Yes -- -- --

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 40 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E1022 Type 1 diabetes mellitus with diabetic chronic kidney disease 18 18 18 30 Yes Yes Yes Yes
E1022 Type 1 diabetes mellitus with diabetic chronic kidney disease 139 Yes -- -- --
E1029 Type 1 diabetes mellitus with other diabetic kidney complication 18 18 18 30 Yes Yes Yes Yes
E1029 Type 1 diabetes mellitus with other diabetic kidney complication 141 Yes -- -- --
E10311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema 18 18 18 30 Yes Yes Yes Yes
E10311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema 241 -- -- -- Yes
E10319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema 18 18 18 30 Yes Yes Yes Yes
E10319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema 241 -- -- -- Yes
E103211 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right 18 18 18 30 Yes Yes Yes Yes
eye
E103211 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right 241 -- -- -- Yes
eye
E103212 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left 18 18 18 30 Yes Yes Yes Yes
eye
E103212 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left 241 -- -- -- Yes
eye
E103213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, 18 18 18 30 Yes Yes Yes Yes
bilateral
E103213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, 241 -- -- -- Yes
bilateral
E103219 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, 18 18 18 30 Yes Yes Yes Yes
unspecified eye
E103219 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, 241 -- -- -- Yes
unspecified eye
E103291 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, 18 18 18 30 Yes Yes Yes Yes
right eye
E103291 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, 241 -- -- -- Yes
right eye
E103292 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left 18 18 18 30 Yes Yes Yes Yes
eye
E103292 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left 241 -- -- -- Yes
eye
E103293 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, 18 18 18 30 Yes Yes Yes Yes
bilateral
E103293 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, 241 -- -- -- Yes
bilateral
E103299 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, 18 18 18 30 Yes Yes Yes Yes
unspecified eye
E103299 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, 241 -- -- -- Yes
unspecified eye
E103311 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, 18 18 18 30 Yes Yes Yes Yes
right eye
E103311 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, 241 -- -- -- Yes
right eye
E103312 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, 18 18 18 30 Yes Yes Yes Yes
left eye
E103312 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, 241 -- -- -- Yes
left eye
E103313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, 18 18 18 30 Yes Yes Yes Yes
bilateral

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 41 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E103313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, 241 -- -- -- Yes
bilateral
E103319 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, 18 18 18 30 Yes Yes Yes Yes
unspecified eye
E103319 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, 241 -- -- -- Yes
unspecified eye
E103391 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, right eye
E103391 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular 241 -- -- -- Yes
edema, right eye
E103392 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, left eye
E103392 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular 241 -- -- -- Yes
edema, left eye
E103393 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, bilateral
E103393 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular 241 -- -- -- Yes
edema, bilateral
E103399 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, unspecified eye
E103399 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular 241 -- -- -- Yes
edema, unspecified eye
E103411 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right 18 18 18 30 Yes Yes Yes Yes
eye
E103411 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right 241 -- -- -- Yes
eye
E103412 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left 18 18 18 30 Yes Yes Yes Yes
eye
E103412 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left 241 -- -- -- Yes
eye
E103413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, 18 18 18 30 Yes Yes Yes Yes
bilateral
E103413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, 241 -- -- -- Yes
bilateral
E103419 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, 18 18 18 30 Yes Yes Yes Yes
unspecified eye
E103419 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, 241 -- -- -- Yes
unspecified eye
E103491 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, 18 18 18 30 Yes Yes Yes Yes
right eye
E103491 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, 241 -- -- -- Yes
right eye
E103492 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, 18 18 18 30 Yes Yes Yes Yes
left eye
E103492 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, 241 -- -- -- Yes
left eye
E103493 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, 18 18 18 30 Yes Yes Yes Yes
bilateral
E103493 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, 241 -- -- -- Yes
bilateral

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 42 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E103499 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, 18 18 18 30 Yes Yes Yes Yes
unspecified eye
E103499 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, 241 -- -- -- Yes
unspecified eye
E103511 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye 18 18 18 30 Yes Yes Yes Yes
E103511 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye 122 122 122 241 Yes Yes Yes Yes
E103512 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye 18 18 18 30 Yes Yes Yes Yes
E103512 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye 122 122 122 241 Yes Yes Yes Yes
E103513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral 18 18 18 30 Yes Yes Yes Yes
E103513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral 122 122 122 241 Yes Yes Yes Yes
E103519 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye 18 18 18 30 Yes Yes Yes Yes
E103519 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye 122 122 122 241 Yes Yes Yes Yes
E103521 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment 18 18 18 30 Yes Yes Yes Yes
involving the macula, right eye
E103521 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment 122 122 122 241 Yes Yes Yes Yes
involving the macula, right eye
E103522 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment 18 18 18 30 Yes Yes Yes Yes
involving the macula, left eye
E103522 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment 122 122 122 241 Yes Yes Yes Yes
involving the macula, left eye
E103523 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment 18 18 18 30 Yes Yes Yes Yes
involving the macula, bilateral
E103523 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment 122 122 122 241 Yes Yes Yes Yes
involving the macula, bilateral
E103529 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment 18 18 18 30 Yes Yes Yes Yes
involving the macula, unspecified eye
E103529 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment 122 122 122 241 Yes Yes Yes Yes
involving the macula, unspecified eye
E103531 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not 18 18 18 30 Yes Yes Yes Yes
involving the macula, right eye
E103531 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not 122 122 122 241 Yes Yes Yes Yes
involving the macula, right eye
E103532 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not 18 18 18 30 Yes Yes Yes Yes
involving the macula, left eye
E103532 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not 122 122 122 241 Yes Yes Yes Yes
involving the macula, left eye
E103533 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not 18 18 18 30 Yes Yes Yes Yes
involving the macula, bilateral
E103533 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not 122 122 122 241 Yes Yes Yes Yes
involving the macula, bilateral
E103539 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not 18 18 18 30 Yes Yes Yes Yes
involving the macula, unspecified eye
E103539 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not 122 122 122 241 Yes Yes Yes Yes
involving the macula, unspecified eye
E103541 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal 18 18 18 30 Yes Yes Yes Yes
detachment and rhegmatogenous retinal detachment, right eye
E103541 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal 122 122 122 241 Yes Yes Yes Yes
detachment and rhegmatogenous retinal detachment, right eye
E103542 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal 18 18 18 30 Yes Yes Yes Yes
detachment and rhegmatogenous retinal detachment, left eye

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 43 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E103542 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal 122 122 122 241 Yes Yes Yes Yes
detachment and rhegmatogenous retinal detachment, left eye
E103543 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal 18 18 18 30 Yes Yes Yes Yes
detachment and rhegmatogenous retinal detachment, bilateral
E103543 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal 122 122 122 241 Yes Yes Yes Yes
detachment and rhegmatogenous retinal detachment, bilateral
E103549 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal 18 18 18 30 Yes Yes Yes Yes
detachment and rhegmatogenous retinal detachment, unspecified eye
E103549 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal 122 122 122 241 Yes Yes Yes Yes
detachment and rhegmatogenous retinal detachment, unspecified eye
E103551 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye 18 18 18 30 Yes Yes Yes Yes
E103551 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye 122 122 122 241 Yes Yes Yes Yes
E103552 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye 18 18 18 30 Yes Yes Yes Yes
E103552 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye 122 122 122 241 Yes Yes Yes Yes
E103553 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral 18 18 18 30 Yes Yes Yes Yes
E103553 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral 122 122 122 241 Yes Yes Yes Yes
E103559 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye 18 18 18 30 Yes Yes Yes Yes
E103559 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye 122 122 122 241 Yes Yes Yes Yes
E103591 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye 18 18 18 30 Yes Yes Yes Yes
E103591 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye 122 122 122 241 Yes Yes Yes Yes
E103592 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye 18 18 18 30 Yes Yes Yes Yes
E103592 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye 122 122 122 241 Yes Yes Yes Yes
E103593 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral 18 18 18 30 Yes Yes Yes Yes
E103593 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral 122 122 122 241 Yes Yes Yes Yes
E103599 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified 18 18 18 30 Yes Yes Yes Yes
eye
E103599 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified 122 122 122 241 Yes Yes Yes Yes
eye
E1036 Type 1 diabetes mellitus with diabetic cataract 18 18 18 30 Yes Yes Yes Yes
E1037X1 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye 18 18 18 30 Yes Yes Yes Yes
E1037X2 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye 18 18 18 30 Yes Yes Yes Yes
E1037X3 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral 18 18 18 30 Yes Yes Yes Yes
E1037X9 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye 18 18 18 30 Yes Yes Yes Yes
E1039 Type 1 diabetes mellitus with other diabetic ophthalmic complication 18 18 18 30 Yes Yes Yes Yes
E1040 Type 1 diabetes mellitus with diabetic neuropathy, unspecified 18 18 18 30 Yes Yes Yes Yes
E1040 Type 1 diabetes mellitus with diabetic neuropathy, unspecified 75 Yes -- -- --
E1041 Type 1 diabetes mellitus with diabetic mononeuropathy 18 18 18 30 Yes Yes Yes Yes
E1041 Type 1 diabetes mellitus with diabetic mononeuropathy 75 Yes -- -- --
E1042 Type 1 diabetes mellitus with diabetic polyneuropathy 18 18 18 30 Yes Yes Yes Yes
E1042 Type 1 diabetes mellitus with diabetic polyneuropathy 75 Yes -- -- --
E1043 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy 18 18 18 30 Yes Yes Yes Yes
E1043 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy 75 Yes -- -- --
E1044 Type 1 diabetes mellitus with diabetic amyotrophy 18 18 18 30 Yes Yes Yes Yes
E1044 Type 1 diabetes mellitus with diabetic amyotrophy 75 Yes -- -- --
E1049 Type 1 diabetes mellitus with other diabetic neurological complication 18 18 18 30 Yes Yes Yes Yes
E1049 Type 1 diabetes mellitus with other diabetic neurological complication 75 Yes -- -- --
E1051 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene 18 18 18 30 Yes Yes Yes Yes
E1051 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene 108 108 108 216 Yes Yes Yes Yes
E1052 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene 18 18 18 30 Yes Yes Yes Yes
E1052 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene 106 106 106 216 Yes Yes Yes Yes
E1052 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene 108 108 108 Yes Yes Yes --

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 44 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E1059 Type 1 diabetes mellitus with other circulatory complications 18 18 18 30 Yes Yes Yes Yes
E10610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy 18 18 18 30 Yes Yes Yes Yes
E10618 Type 1 diabetes mellitus with other diabetic arthropathy 18 18 18 30 Yes Yes Yes Yes
E10620 Type 1 diabetes mellitus with diabetic dermatitis 18 18 18 30 Yes Yes Yes Yes
E10621 Type 1 diabetes mellitus with foot ulcer 18 18 18 30 Yes Yes Yes Yes
E10621 Type 1 diabetes mellitus with foot ulcer 161 161 161 311 Yes Yes Yes Yes
E10622 Type 1 diabetes mellitus with other skin ulcer 18 18 18 30 Yes Yes Yes Yes
E10622 Type 1 diabetes mellitus with other skin ulcer 161 161 161 311 Yes Yes Yes Yes
E10628 Type 1 diabetes mellitus with other skin complications 18 18 18 30 Yes Yes Yes Yes
E10630 Type 1 diabetes mellitus with periodontal disease 18 18 18 30 Yes Yes Yes Yes
E10638 Type 1 diabetes mellitus with other oral complications 18 18 18 30 Yes Yes Yes Yes
E10641 Type 1 diabetes mellitus with hypoglycemia with coma 17 17 17 30 Yes Yes Yes Yes
E10649 Type 1 diabetes mellitus with hypoglycemia without coma 18 18 18 30 Yes Yes Yes Yes
E1065 Type 1 diabetes mellitus with hyperglycemia 18 18 18 30 Yes Yes Yes Yes
E1069 Type 1 diabetes mellitus with other specified complication 18 18 18 30 Yes Yes Yes Yes
E108 Type 1 diabetes mellitus with unspecified complications 18 18 18 30 Yes Yes Yes Yes
E109 Type 1 diabetes mellitus without complications 19 19 19 31 Yes Yes Yes Yes
E1100 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar 17 17 17 30 Yes Yes Yes Yes
coma (NKHHC)
E1101 Type 2 diabetes mellitus with hyperosmolarity with coma 17 17 17 30 Yes Yes Yes Yes
E1110 Type 2 diabetes mellitus with ketoacidosis without coma 17 17 17 30 Yes Yes Yes Yes
E1111 Type 2 diabetes mellitus with ketoacidosis with coma 17 17 17 30 Yes Yes Yes Yes
E1121 Type 2 diabetes mellitus with diabetic nephropathy 18 18 18 30 Yes Yes Yes Yes
E1121 Type 2 diabetes mellitus with diabetic nephropathy 141 Yes -- -- --
E1122 Type 2 diabetes mellitus with diabetic chronic kidney disease 18 18 18 30 Yes Yes Yes Yes
E1122 Type 2 diabetes mellitus with diabetic chronic kidney disease 139 Yes -- -- --
E1129 Type 2 diabetes mellitus with other diabetic kidney complication 18 18 18 30 Yes Yes Yes Yes
E1129 Type 2 diabetes mellitus with other diabetic kidney complication 141 Yes -- -- --
E11311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema 18 18 18 30 Yes Yes Yes Yes
E11311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema 241 -- -- -- Yes
E11319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema 18 18 18 30 Yes Yes Yes Yes
E11319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema 241 -- -- -- Yes
E113211 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right 18 18 18 30 Yes Yes Yes Yes
eye
E113211 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right 241 -- -- -- Yes
eye
E113212 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left 18 18 18 30 Yes Yes Yes Yes
eye
E113212 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left 241 -- -- -- Yes
eye
E113213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, 18 18 18 30 Yes Yes Yes Yes
bilateral
E113213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, 241 -- -- -- Yes
bilateral
E113219 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, 18 18 18 30 Yes Yes Yes Yes
unspecified eye
E113219 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, 241 -- -- -- Yes
unspecified eye
E113291 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, 18 18 18 30 Yes Yes Yes Yes
right eye

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 45 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E113291 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, 241 -- -- -- Yes
right eye
E113292 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left 18 18 18 30 Yes Yes Yes Yes
eye
E113292 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left 241 -- -- -- Yes
eye
E113293 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, 18 18 18 30 Yes Yes Yes Yes
bilateral
E113293 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, 241 -- -- -- Yes
bilateral
E113299 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, 18 18 18 30 Yes Yes Yes Yes
unspecified eye
E113299 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, 241 -- -- -- Yes
unspecified eye
E113311 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, 18 18 18 30 Yes Yes Yes Yes
right eye
E113311 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, 241 -- -- -- Yes
right eye
E113312 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, 18 18 18 30 Yes Yes Yes Yes
left eye
E113312 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, 241 -- -- -- Yes
left eye
E113313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, 18 18 18 30 Yes Yes Yes Yes
bilateral
E113313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, 241 -- -- -- Yes
bilateral
E113319 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, 18 18 18 30 Yes Yes Yes Yes
unspecified eye
E113319 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, 241 -- -- -- Yes
unspecified eye
E113391 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, right eye
E113391 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular 241 -- -- -- Yes
edema, right eye
E113392 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, left eye
E113392 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular 241 -- -- -- Yes
edema, left eye
E113393 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, bilateral
E113393 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular 241 -- -- -- Yes
edema, bilateral
E113399 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, unspecified eye
E113399 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular 241 -- -- -- Yes
edema, unspecified eye
E113411 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right 18 18 18 30 Yes Yes Yes Yes
eye
E113411 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right 241 -- -- -- Yes
eye

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 46 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E113412 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left 18 18 18 30 Yes Yes Yes Yes
eye
E113412 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left 241 -- -- -- Yes
eye
E113413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, 18 18 18 30 Yes Yes Yes Yes
bilateral
E113413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, 241 -- -- -- Yes
bilateral
E113419 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, 18 18 18 30 Yes Yes Yes Yes
unspecified eye
E113419 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, 241 -- -- -- Yes
unspecified eye
E113491 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, 18 18 18 30 Yes Yes Yes Yes
right eye
E113491 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, 241 -- -- -- Yes
right eye
E113492 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, 18 18 18 30 Yes Yes Yes Yes
left eye
E113492 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, 241 -- -- -- Yes
left eye
E113493 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, 18 18 18 30 Yes Yes Yes Yes
bilateral
E113493 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, 241 -- -- -- Yes
bilateral
E113499 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, 18 18 18 30 Yes Yes Yes Yes
unspecified eye
E113499 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, 241 -- -- -- Yes
unspecified eye
E113511 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye 18 18 18 30 Yes Yes Yes Yes
E113511 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye 122 122 122 241 Yes Yes Yes Yes
E113512 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye 18 18 18 30 Yes Yes Yes Yes
E113512 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye 122 122 122 241 Yes Yes Yes Yes
E113513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral 18 18 18 30 Yes Yes Yes Yes
E113513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral 122 122 122 241 Yes Yes Yes Yes
E113519 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye 18 18 18 30 Yes Yes Yes Yes
E113519 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye 122 122 122 241 Yes Yes Yes Yes
E113521 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment 18 18 18 30 Yes Yes Yes Yes
involving the macula, right eye
E113521 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment 122 122 122 241 Yes Yes Yes Yes
involving the macula, right eye
E113522 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment 18 18 18 30 Yes Yes Yes Yes
involving the macula, left eye
E113522 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment 122 122 122 241 Yes Yes Yes Yes
involving the macula, left eye
E113523 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment 18 18 18 30 Yes Yes Yes Yes
involving the macula, bilateral
E113523 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment 122 122 122 241 Yes Yes Yes Yes
involving the macula, bilateral
E113529 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment 18 18 18 30 Yes Yes Yes Yes
involving the macula, unspecified eye

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 47 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E113529 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment 122 122 122 241 Yes Yes Yes Yes
involving the macula, unspecified eye
E113531 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not 18 18 18 30 Yes Yes Yes Yes
involving the macula, right eye
E113531 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not 122 122 122 241 Yes Yes Yes Yes
involving the macula, right eye
E113532 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not 18 18 18 30 Yes Yes Yes Yes
involving the macula, left eye
E113532 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not 122 122 122 241 Yes Yes Yes Yes
involving the macula, left eye
E113533 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not 18 18 18 30 Yes Yes Yes Yes
involving the macula, bilateral
E113533 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not 122 122 122 241 Yes Yes Yes Yes
involving the macula, bilateral
E113539 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not 18 18 18 30 Yes Yes Yes Yes
involving the macula, unspecified eye
E113539 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not 122 122 122 241 Yes Yes Yes Yes
involving the macula, unspecified eye
E113541 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal 18 18 18 30 Yes Yes Yes Yes
detachment and rhegmatogenous retinal detachment, right eye
E113541 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal 122 122 122 241 Yes Yes Yes Yes
detachment and rhegmatogenous retinal detachment, right eye
E113542 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal 18 18 18 30 Yes Yes Yes Yes
detachment and rhegmatogenous retinal detachment, left eye
E113542 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal 122 122 122 241 Yes Yes Yes Yes
detachment and rhegmatogenous retinal detachment, left eye
E113543 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal 18 18 18 30 Yes Yes Yes Yes
detachment and rhegmatogenous retinal detachment, bilateral
E113543 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal 122 122 122 241 Yes Yes Yes Yes
detachment and rhegmatogenous retinal detachment, bilateral
E113549 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal 18 18 18 30 Yes Yes Yes Yes
detachment and rhegmatogenous retinal detachment, unspecified eye
E113549 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal 122 122 122 241 Yes Yes Yes Yes
detachment and rhegmatogenous retinal detachment, unspecified eye
E113551 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye 18 18 18 30 Yes Yes Yes Yes
E113551 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye 122 122 122 241 Yes Yes Yes Yes
E113552 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye 18 18 18 30 Yes Yes Yes Yes
E113552 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye 122 122 122 241 Yes Yes Yes Yes
E113553 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral 18 18 18 30 Yes Yes Yes Yes
E113553 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral 122 122 122 241 Yes Yes Yes Yes
E113559 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye 18 18 18 30 Yes Yes Yes Yes
E113559 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye 122 122 122 241 Yes Yes Yes Yes
E113591 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye 18 18 18 30 Yes Yes Yes Yes
E113591 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye 122 122 122 241 Yes Yes Yes Yes
E113592 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye 18 18 18 30 Yes Yes Yes Yes
E113592 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye 122 122 122 241 Yes Yes Yes Yes
E113593 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral 18 18 18 30 Yes Yes Yes Yes
E113593 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral 122 122 122 241 Yes Yes Yes Yes
E113599 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified 18 18 18 30 Yes Yes Yes Yes
eye

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 48 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E113599 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified 122 122 122 241 Yes Yes Yes Yes
eye
E1136 Type 2 diabetes mellitus with diabetic cataract 18 18 18 30 Yes Yes Yes Yes
E1137X1 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye 18 18 18 30 Yes Yes Yes Yes
E1137X2 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye 18 18 18 30 Yes Yes Yes Yes
E1137X3 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral 18 18 18 30 Yes Yes Yes Yes
E1137X9 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye 18 18 18 30 Yes Yes Yes Yes
E1139 Type 2 diabetes mellitus with other diabetic ophthalmic complication 18 18 18 30 Yes Yes Yes Yes
E1140 Type 2 diabetes mellitus with diabetic neuropathy, unspecified 18 18 18 30 Yes Yes Yes Yes
E1140 Type 2 diabetes mellitus with diabetic neuropathy, unspecified 75 Yes -- -- --
E1141 Type 2 diabetes mellitus with diabetic mononeuropathy 18 18 18 30 Yes Yes Yes Yes
E1141 Type 2 diabetes mellitus with diabetic mononeuropathy 75 Yes -- -- --
E1142 Type 2 diabetes mellitus with diabetic polyneuropathy 18 18 18 30 Yes Yes Yes Yes
E1142 Type 2 diabetes mellitus with diabetic polyneuropathy 75 Yes -- -- --
E1143 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy 18 18 18 30 Yes Yes Yes Yes
E1143 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy 75 Yes -- -- --
E1144 Type 2 diabetes mellitus with diabetic amyotrophy 18 18 18 30 Yes Yes Yes Yes
E1144 Type 2 diabetes mellitus with diabetic amyotrophy 75 Yes -- -- --
E1149 Type 2 diabetes mellitus with other diabetic neurological complication 18 18 18 30 Yes Yes Yes Yes
E1149 Type 2 diabetes mellitus with other diabetic neurological complication 75 Yes -- -- --
E1151 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene 18 18 18 30 Yes Yes Yes Yes
E1151 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene 108 108 108 216 Yes Yes Yes Yes
E1152 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene 18 18 18 30 Yes Yes Yes Yes
E1152 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene 106 106 106 216 Yes Yes Yes Yes
E1152 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene 108 108 108 Yes Yes Yes --
E1159 Type 2 diabetes mellitus with other circulatory complications 18 18 18 30 Yes Yes Yes Yes
E11610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy 18 18 18 30 Yes Yes Yes Yes
E11618 Type 2 diabetes mellitus with other diabetic arthropathy 18 18 18 30 Yes Yes Yes Yes
E11620 Type 2 diabetes mellitus with diabetic dermatitis 18 18 18 30 Yes Yes Yes Yes
E11621 Type 2 diabetes mellitus with foot ulcer 18 18 18 30 Yes Yes Yes Yes
E11621 Type 2 diabetes mellitus with foot ulcer 161 161 161 311 Yes Yes Yes Yes
E11622 Type 2 diabetes mellitus with other skin ulcer 18 18 18 30 Yes Yes Yes Yes
E11622 Type 2 diabetes mellitus with other skin ulcer 161 161 161 311 Yes Yes Yes Yes
E11628 Type 2 diabetes mellitus with other skin complications 18 18 18 30 Yes Yes Yes Yes
E11630 Type 2 diabetes mellitus with periodontal disease 18 18 18 30 Yes Yes Yes Yes
E11638 Type 2 diabetes mellitus with other oral complications 18 18 18 30 Yes Yes Yes Yes
E11641 Type 2 diabetes mellitus with hypoglycemia with coma 17 17 17 30 Yes Yes Yes Yes
E11649 Type 2 diabetes mellitus with hypoglycemia without coma 18 18 18 30 Yes Yes Yes Yes
E1165 Type 2 diabetes mellitus with hyperglycemia 18 18 18 30 Yes Yes Yes Yes
E1169 Type 2 diabetes mellitus with other specified complication 18 18 18 30 Yes Yes Yes Yes
E118 Type 2 diabetes mellitus with unspecified complications 18 18 18 30 Yes Yes Yes Yes
E119 Type 2 diabetes mellitus without complications 19 19 19 31 Yes Yes Yes Yes
E1300 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic- 17 17 17 30 Yes Yes Yes Yes
hyperosmolar coma (NKHHC)
E1301 Other specified diabetes mellitus with hyperosmolarity with coma 17 17 17 30 Yes Yes Yes Yes
E1310 Other specified diabetes mellitus with ketoacidosis without coma 17 17 17 30 Yes Yes Yes Yes
E1311 Other specified diabetes mellitus with ketoacidosis with coma 17 17 17 30 Yes Yes Yes Yes
E1321 Other specified diabetes mellitus with diabetic nephropathy 18 18 18 30 Yes Yes Yes Yes
E1321 Other specified diabetes mellitus with diabetic nephropathy 141 Yes -- -- --
E1322 Other specified diabetes mellitus with diabetic chronic kidney disease 18 18 18 30 Yes Yes Yes Yes
E1322 Other specified diabetes mellitus with diabetic chronic kidney disease 139 Yes -- -- --

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 49 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E1329 Other specified diabetes mellitus with other diabetic kidney complication 18 18 18 30 Yes Yes Yes Yes
E1329 Other specified diabetes mellitus with other diabetic kidney complication 141 Yes -- -- --
E13311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema 18 18 18 30 Yes Yes Yes Yes
E13311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema 241 -- -- -- Yes
E13319 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema 18 18 18 30 Yes Yes Yes Yes
E13319 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema 241 -- -- -- Yes
E133211 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, right eye
E133211 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular 241 -- -- -- Yes
edema, right eye
E133212 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, left eye
E133212 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular 241 -- -- -- Yes
edema, left eye
E133213 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, bilateral
E133213 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular 241 -- -- -- Yes
edema, bilateral
E133219 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, unspecified eye
E133219 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular 241 -- -- -- Yes
edema, unspecified eye
E133291 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, right eye
E133291 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular 241 -- -- -- Yes
edema, right eye
E133292 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, left eye
E133292 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular 241 -- -- -- Yes
edema, left eye
E133293 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, bilateral
E133293 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular 241 -- -- -- Yes
edema, bilateral
E133299 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, unspecified eye
E133299 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular 241 -- -- -- Yes
edema, unspecified eye
E133311 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, right eye
E133311 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular 241 -- -- -- Yes
edema, right eye
E133312 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, left eye
E133312 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular 241 -- -- -- Yes
edema, left eye
E133313 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, bilateral
E133313 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular 241 -- -- -- Yes
edema, bilateral

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 50 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E133319 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, unspecified eye
E133319 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular 241 -- -- -- Yes
edema, unspecified eye
E133391 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without 18 18 18 30 Yes Yes Yes Yes
macular edema, right eye
E133391 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without 241 -- -- -- Yes
macular edema, right eye
E133392 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without 18 18 18 30 Yes Yes Yes Yes
macular edema, left eye
E133392 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without 241 -- -- -- Yes
macular edema, left eye
E133393 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without 18 18 18 30 Yes Yes Yes Yes
macular edema, bilateral
E133393 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without 241 -- -- -- Yes
macular edema, bilateral
E133399 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without 18 18 18 30 Yes Yes Yes Yes
macular edema, unspecified eye
E133399 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without 241 -- -- -- Yes
macular edema, unspecified eye
E133411 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, right eye
E133411 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular 241 -- -- -- Yes
edema, right eye
E133412 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, left eye
E133412 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular 241 -- -- -- Yes
edema, left eye
E133413 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, bilateral
E133413 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular 241 -- -- -- Yes
edema, bilateral
E133419 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular 18 18 18 30 Yes Yes Yes Yes
edema, unspecified eye
E133419 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular 241 -- -- -- Yes
edema, unspecified eye
E133491 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, right eye
E133491 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular 241 -- -- -- Yes
edema, right eye
E133492 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, left eye
E133492 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular 241 -- -- -- Yes
edema, left eye
E133493 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, bilateral
E133493 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular 241 -- -- -- Yes
edema, bilateral
E133499 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular 18 18 18 30 Yes Yes Yes Yes
edema, unspecified eye

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 51 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E133499 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular 241 -- -- -- Yes
edema, unspecified eye
E133511 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right 18 18 18 30 Yes Yes Yes Yes
eye
E133511 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right 122 122 122 241 Yes Yes Yes Yes
eye
E133512 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye 18 18 18 30 Yes Yes Yes Yes
E133512 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye 122 122 122 241 Yes Yes Yes Yes
E133513 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, 18 18 18 30 Yes Yes Yes Yes
bilateral
E133513 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, 122 122 122 241 Yes Yes Yes Yes
bilateral
E133519 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, 18 18 18 30 Yes Yes Yes Yes
unspecified eye
E133519 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, 122 122 122 241 Yes Yes Yes Yes
unspecified eye
E133521 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal 18 18 18 30 Yes Yes Yes Yes
detachment involving the macula, right eye
E133521 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal 122 122 122 241 Yes Yes Yes Yes
detachment involving the macula, right eye
E133522 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal 18 18 18 30 Yes Yes Yes Yes
detachment involving the macula, left eye
E133522 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal 122 122 122 241 Yes Yes Yes Yes
detachment involving the macula, left eye
E133523 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal 18 18 18 30 Yes Yes Yes Yes
detachment involving the macula, bilateral
E133523 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal 122 122 122 241 Yes Yes Yes Yes
detachment involving the macula, bilateral
E133529 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal 18 18 18 30 Yes Yes Yes Yes
detachment involving the macula, unspecified eye
E133529 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal 122 122 122 241 Yes Yes Yes Yes
detachment involving the macula, unspecified eye
E133531 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal 18 18 18 30 Yes Yes Yes Yes
detachment not involving the macula, right eye
E133531 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal 122 122 122 241 Yes Yes Yes Yes
detachment not involving the macula, right eye
E133532 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal 18 18 18 30 Yes Yes Yes Yes
detachment not involving the macula, left eye
E133532 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal 122 122 122 241 Yes Yes Yes Yes
detachment not involving the macula, left eye
E133533 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal 18 18 18 30 Yes Yes Yes Yes
detachment not involving the macula, bilateral
E133533 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal 122 122 122 241 Yes Yes Yes Yes
detachment not involving the macula, bilateral
E133539 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal 18 18 18 30 Yes Yes Yes Yes
detachment not involving the macula, unspecified eye
E133539 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal 122 122 122 241 Yes Yes Yes Yes
detachment not involving the macula, unspecified eye
E133541 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment and rhegmatogenous retinal detachment, right eye

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 52 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E133541 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment and rhegmatogenous retinal detachment, right eye
E133542 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment and rhegmatogenous retinal detachment, left eye
E133542 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment and rhegmatogenous retinal detachment, left eye
E133543 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment and rhegmatogenous retinal detachment, bilateral
E133543 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment and rhegmatogenous retinal detachment, bilateral
E133549 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction 18 18 18 30 Yes Yes Yes Yes
retinal detachment and rhegmatogenous retinal detachment, unspecified eye
E133549 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction 122 122 122 241 Yes Yes Yes Yes
retinal detachment and rhegmatogenous retinal detachment, unspecified eye
E133551 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye 18 18 18 30 Yes Yes Yes Yes
E133551 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye 122 122 122 241 Yes Yes Yes Yes
E133552 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye 18 18 18 30 Yes Yes Yes Yes
E133552 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye 122 122 122 241 Yes Yes Yes Yes
E133553 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral 18 18 18 30 Yes Yes Yes Yes
E133553 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral 122 122 122 241 Yes Yes Yes Yes
E133559 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye 18 18 18 30 Yes Yes Yes Yes
E133559 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye 122 122 122 241 Yes Yes Yes Yes
E133591 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, 18 18 18 30 Yes Yes Yes Yes
right eye
E133591 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, 122 122 122 241 Yes Yes Yes Yes
right eye
E133592 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left 18 18 18 30 Yes Yes Yes Yes
eye
E133592 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left 122 122 122 241 Yes Yes Yes Yes
eye
E133593 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, 18 18 18 30 Yes Yes Yes Yes
bilateral
E133593 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, 122 122 122 241 Yes Yes Yes Yes
bilateral
E133599 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, 18 18 18 30 Yes Yes Yes Yes
unspecified eye
E133599 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, 122 122 122 241 Yes Yes Yes Yes
unspecified eye
E1336 Other specified diabetes mellitus with diabetic cataract 18 18 18 30 Yes Yes Yes Yes
E1337X1 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, right 18 18 18 30 Yes Yes Yes Yes
eye
E1337X2 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, left 18 18 18 30 Yes Yes Yes Yes
E1337X3 eye
Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, 18 18 18 30 Yes Yes Yes Yes
bilateral
E1337X9 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, 18 18 18 30 Yes Yes Yes Yes
unspecified eye
E1339 Other specified diabetes mellitus with other diabetic ophthalmic complication 18 18 18 30 Yes Yes Yes Yes
E1340 Other specified diabetes mellitus with diabetic neuropathy, unspecified 18 18 18 30 Yes Yes Yes Yes
E1340 Other specified diabetes mellitus with diabetic neuropathy, unspecified 75 Yes -- -- --
E1341 Other specified diabetes mellitus with diabetic mononeuropathy 18 18 18 30 Yes Yes Yes Yes
E1341 Other specified diabetes mellitus with diabetic mononeuropathy 75 Yes -- -- --

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 53 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E1342 Other specified diabetes mellitus with diabetic polyneuropathy 18 18 18 30 Yes Yes Yes Yes
E1342 Other specified diabetes mellitus with diabetic polyneuropathy 75 Yes -- -- --
E1343 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy 18 18 18 30 Yes Yes Yes Yes
E1343 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy 75 Yes -- -- --
E1344 Other specified diabetes mellitus with diabetic amyotrophy 18 18 18 30 Yes Yes Yes Yes
E1344 Other specified diabetes mellitus with diabetic amyotrophy 75 Yes -- -- --
E1349 Other specified diabetes mellitus with other diabetic neurological complication 18 18 18 30 Yes Yes Yes Yes
E1349 Other specified diabetes mellitus with other diabetic neurological complication 75 Yes -- -- --
E1351 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene 18 18 18 30 Yes Yes Yes Yes
E1351 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene 108 108 108 216 Yes Yes Yes Yes
E1352 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene 18 18 18 30 Yes Yes Yes Yes
E1352 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene 106 106 106 216 Yes Yes Yes Yes
E1352 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene 108 108 108 Yes Yes Yes --
E1359 Other specified diabetes mellitus with other circulatory complications 18 18 18 30 Yes Yes Yes Yes
E13610 Other specified diabetes mellitus with diabetic neuropathic arthropathy 18 18 18 30 Yes Yes Yes Yes
E13618 Other specified diabetes mellitus with other diabetic arthropathy 18 18 18 30 Yes Yes Yes Yes
E13620 Other specified diabetes mellitus with diabetic dermatitis 18 18 18 30 Yes Yes Yes Yes
E13621 Other specified diabetes mellitus with foot ulcer 18 18 18 30 Yes Yes Yes Yes
E13621 Other specified diabetes mellitus with foot ulcer 161 161 161 311 Yes Yes Yes Yes
E13622 Other specified diabetes mellitus with other skin ulcer 18 18 18 30 Yes Yes Yes Yes
E13622 Other specified diabetes mellitus with other skin ulcer 161 161 161 311 Yes Yes Yes Yes
E13628 Other specified diabetes mellitus with other skin complications 18 18 18 30 Yes Yes Yes Yes
E13630 Other specified diabetes mellitus with periodontal disease 18 18 18 30 Yes Yes Yes Yes
E13638 Other specified diabetes mellitus with other oral complications 18 18 18 30 Yes Yes Yes Yes
E13641 Other specified diabetes mellitus with hypoglycemia with coma 17 17 17 30 Yes Yes Yes Yes
E13649 Other specified diabetes mellitus with hypoglycemia without coma 18 18 18 30 Yes Yes Yes Yes
E1365 Other specified diabetes mellitus with hyperglycemia 18 18 18 30 Yes Yes Yes Yes
E1369 Other specified diabetes mellitus with other specified complication 18 18 18 30 Yes Yes Yes Yes
E138 Other specified diabetes mellitus with unspecified complications 18 18 18 30 Yes Yes Yes Yes
E139 Other specified diabetes mellitus without complications 19 19 19 31 Yes Yes Yes Yes
E15 Nondiabetic hypoglycemic coma 23 23 23 Yes Yes Yes No
E163 Increased secretion of glucagon 66 No No No Yes
E164 Increased secretion of gastrin 66 No No No Yes
E168 Other specified disorders of pancreatic internal secretion 66 No No No Yes
E169 Disorder of pancreatic internal secretion, unspecified 66 No No No Yes
E200 Idiopathic hypoparathyroidism 23 23 23 41 Yes Yes Yes Yes
E208 Other hypoparathyroidism 23 23 23 41 Yes Yes Yes Yes
E209 Hypoparathyroidism, unspecified 23 23 23 41 Yes Yes Yes Yes
E210 Primary hyperparathyroidism 23 23 23 41 Yes Yes Yes Yes
E211 Secondary hyperparathyroidism, not elsewhere classified 23 23 23 41 Yes Yes Yes Yes
E212 Other hyperparathyroidism 23 23 23 41 Yes Yes Yes Yes
E213 Hyperparathyroidism, unspecified 23 23 23 41 Yes Yes Yes Yes
E214 Other specified disorders of parathyroid gland 23 23 23 41 Yes Yes Yes Yes
E215 Disorder of parathyroid gland, unspecified 23 23 23 41 Yes Yes Yes Yes
E220 Acromegaly and pituitary gigantism 23 23 23 41 Yes Yes Yes Yes
E221 Hyperprolactinemia 23 23 23 41 Yes Yes Yes Yes
E222 Syndrome of inappropriate secretion of antidiuretic hormone 23 23 23 41 Yes Yes Yes Yes
E228 Other hyperfunction of pituitary gland 23 23 23 41 Yes Yes Yes Yes
E229 Hyperfunction of pituitary gland, unspecified 23 23 23 41 Yes Yes Yes Yes
E230 Hypopituitarism 23 23 23 41 Yes Yes Yes Yes
E231 Drug-induced hypopituitarism 23 23 23 41 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 54 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E232 Diabetes insipidus 23 23 23 41 Yes Yes Yes Yes


E233 Hypothalamic dysfunction, not elsewhere classified 23 23 23 41 Yes Yes Yes Yes
E236 Other disorders of pituitary gland 23 23 23 41 Yes Yes Yes Yes
E237 Disorder of pituitary gland, unspecified 23 23 23 41 Yes Yes Yes Yes
E240 Pituitary-dependent Cushing's disease 23 23 23 41 Yes Yes Yes Yes
E241 Nelson's syndrome 23 23 23 41 Yes Yes Yes Yes
E242 Drug-induced Cushing's syndrome 23 23 23 41 Yes Yes Yes Yes
E243 Ectopic ACTH syndrome 23 23 23 41 Yes Yes Yes Yes
E244 Alcohol-induced pseudo-Cushing's syndrome 23 23 23 41 Yes Yes Yes Yes
E248 Other Cushing's syndrome 23 23 23 41 Yes Yes Yes Yes
E249 Cushing's syndrome, unspecified 23 23 23 41 Yes Yes Yes Yes
E250 Congenital adrenogenital disorders associated with enzyme deficiency 23 23 23 41 Yes Yes Yes Yes
E258 Other adrenogenital disorders 23 23 23 41 Yes Yes Yes Yes
E259 Adrenogenital disorder, unspecified 23 23 23 41 Yes Yes Yes Yes
E2601 Conn's syndrome 23 23 23 41 Yes Yes Yes Yes
E2602 Glucocorticoid-remediable aldosteronism 23 23 23 41 Yes Yes Yes Yes
E2609 Other primary hyperaldosteronism 23 23 23 41 Yes Yes Yes Yes
E261 Secondary hyperaldosteronism 23 23 23 41 Yes Yes Yes Yes
E2681 Bartter's syndrome 23 23 23 41 Yes Yes Yes Yes
E2689 Other hyperaldosteronism 23 23 23 41 Yes Yes Yes Yes
E269 Hyperaldosteronism, unspecified 23 23 23 41 Yes Yes Yes Yes
E270 Other adrenocortical overactivity 23 23 23 41 Yes Yes Yes Yes
E271 Primary adrenocortical insufficiency 23 23 23 41 Yes Yes Yes Yes
E272 Addisonian crisis 23 23 23 41 Yes Yes Yes Yes
E273 Drug-induced adrenocortical insufficiency 23 23 23 41 Yes Yes Yes Yes
E2740 Unspecified adrenocortical insufficiency 23 23 23 41 Yes Yes Yes Yes
E2749 Other adrenocortical insufficiency 23 23 23 41 Yes Yes Yes Yes
E275 Adrenomedullary hyperfunction 23 23 23 41 Yes Yes Yes Yes
E278 Other specified disorders of adrenal gland 23 23 23 41 Yes Yes Yes Yes
E279 Disorder of adrenal gland, unspecified 23 23 23 41 Yes Yes Yes Yes
E310 Autoimmune polyglandular failure 23 23 23 41 Yes Yes Yes Yes
E311 Polyglandular hyperfunction 23 23 23 41 Yes Yes Yes Yes
E3120 Multiple endocrine neoplasia [MEN] syndrome, unspecified 23 23 23 41 Yes Yes Yes Yes
E3121 Multiple endocrine neoplasia [MEN] type I 23 23 23 41 Yes Yes Yes Yes
E3122 Multiple endocrine neoplasia [MEN] type IIA 23 23 23 41 Yes Yes Yes Yes
E3123 Multiple endocrine neoplasia [MEN] type IIB 23 23 23 41 Yes Yes Yes Yes
E318 Other polyglandular dysfunction 23 23 23 41 Yes Yes Yes Yes
E319 Polyglandular dysfunction, unspecified 23 23 23 41 Yes Yes Yes Yes
E320 Persistent hyperplasia of thymus 23 23 23 41 Yes Yes Yes Yes
E321 Abscess of thymus 23 23 23 41 Yes Yes Yes Yes
E328 Other diseases of thymus 23 23 23 41 Yes Yes Yes Yes
E329 Disease of thymus, unspecified 23 23 23 41 Yes Yes Yes Yes
E340 Carcinoid syndrome 12 12 12 19 Yes Yes Yes Yes
E344 Constitutional tall stature 23 23 23 41 Yes Yes Yes Yes
E40 Kwashiorkor 21 21 21 Yes Yes Yes No
E41 Nutritional marasmus 21 21 21 Yes Yes Yes No
E42 Marasmic kwashiorkor 21 21 21 Yes Yes Yes No
E43 Unspecified severe protein-calorie malnutrition 21 21 21 Yes Yes Yes No
E440 Moderate protein-calorie malnutrition 21 21 21 Yes Yes Yes No
E441 Mild protein-calorie malnutrition 21 21 21 Yes Yes Yes No
E45 Retarded development following protein-calorie malnutrition 21 21 21 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 55 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E46 Unspecified protein-calorie malnutrition 21 21 21 Yes Yes Yes No


E550 Rickets, active 87 No No No Yes
E640 Sequelae of protein-calorie malnutrition 21 21 21 Yes Yes Yes No
E6601 Morbid (severe) obesity due to excess calories 22 22 22 43 Yes Yes Yes Yes
E662 Morbid (severe) obesity with alveolar hypoventilation 22 22 22 43 Yes Yes Yes Yes
E700 Classical phenylketonuria 23 23 23 41 Yes Yes Yes Yes
E701 Other hyperphenylalaninemias 23 23 23 41 Yes Yes Yes Yes
E7020 Disorder of tyrosine metabolism, unspecified 23 23 23 41 Yes Yes Yes Yes
E7021 Tyrosinemia 23 23 23 41 Yes Yes Yes Yes
E7029 Other disorders of tyrosine metabolism 23 23 23 41 Yes Yes Yes Yes
E7030 Albinism, unspecified 23 23 23 41 Yes Yes Yes Yes
E70310 X-linked ocular albinism 23 23 23 41 Yes Yes Yes Yes
E70311 Autosomal recessive ocular albinism 23 23 23 41 Yes Yes Yes Yes
E70318 Other ocular albinism 23 23 23 41 Yes Yes Yes Yes
E70319 Ocular albinism, unspecified 23 23 23 41 Yes Yes Yes Yes
E70320 Tyrosinase negative oculocutaneous albinism 23 23 23 41 Yes Yes Yes Yes
E70321 Tyrosinase positive oculocutaneous albinism 23 23 23 41 Yes Yes Yes Yes
E70328 Other oculocutaneous albinism 23 23 23 41 Yes Yes Yes Yes
E70329 Oculocutaneous albinism, unspecified 23 23 23 41 Yes Yes Yes Yes
E70330 Chediak-Higashi syndrome 23 23 23 41 Yes Yes Yes Yes
E70331 Hermansky-Pudlak syndrome 23 23 23 41 Yes Yes Yes Yes
E70338 Other albinism with hematologic abnormality 23 23 23 41 Yes Yes Yes Yes
E70339 Albinism with hematologic abnormality, unspecified 23 23 23 41 Yes Yes Yes Yes
E7039 Other specified albinism 23 23 23 41 Yes Yes Yes Yes
E7040 Disorders of histidine metabolism, unspecified 23 23 23 41 Yes Yes Yes Yes
E7041 Histidinemia 23 23 23 41 Yes Yes Yes Yes
E7049 Other disorders of histidine metabolism 23 23 23 41 Yes Yes Yes Yes
E705 Disorders of tryptophan metabolism 23 23 23 41 Yes Yes Yes Yes
E708 Other disorders of aromatic amino-acid metabolism 23 23 23 41 Yes Yes Yes Yes
E7081 Aromatic L-amino acid decarboxylase deficiency 23 23 23 41 Yes Yes Yes Yes
E7089 Other disorders of aromatic amino-acid metabolism 23 23 23 41 Yes Yes Yes Yes
E709 Disorder of aromatic amino-acid metabolism, unspecified 23 23 23 41 Yes Yes Yes Yes
E710 Maple-syrup-urine disease 23 23 23 41 Yes Yes Yes Yes
E71110 Isovaleric acidemia 23 23 23 41 Yes Yes Yes Yes
E71111 3-methylglutaconic aciduria 23 23 23 41 Yes Yes Yes Yes
E71118 Other branched-chain organic acidurias 23 23 23 41 Yes Yes Yes Yes
E71120 Methylmalonic acidemia 23 23 23 41 Yes Yes Yes Yes
E71121 Propionic acidemia 23 23 23 41 Yes Yes Yes Yes
E71128 Other disorders of propionate metabolism 23 23 23 41 Yes Yes Yes Yes
E7119 Other disorders of branched-chain amino-acid metabolism 23 23 23 41 Yes Yes Yes Yes
E712 Disorder of branched-chain amino-acid metabolism, unspecified 23 23 23 41 Yes Yes Yes Yes
E7130 Disorder of fatty-acid metabolism, unspecified 45 No No No Yes
E71310 Long chain/very long chain acyl CoA dehydrogenase deficiency 23 23 23 41 Yes Yes Yes Yes
E71311 Medium chain acyl CoA dehydrogenase deficiency 23 23 23 41 Yes Yes Yes Yes
E71312 Short chain acyl CoA dehydrogenase deficiency 23 23 23 41 Yes Yes Yes Yes
E71313 Glutaric aciduria type II 23 23 23 41 Yes Yes Yes Yes
E71314 Muscle carnitine palmitoyltransferase deficiency 23 23 23 41 Yes Yes Yes Yes
E71318 Other disorders of fatty-acid oxidation 23 23 23 41 Yes Yes Yes Yes
E7132 Disorders of ketone metabolism 23 23 23 41 Yes Yes Yes Yes
E7139 Other disorders of fatty-acid metabolism 23 23 23 41 Yes Yes Yes Yes
E7140 Disorder of carnitine metabolism, unspecified 23 23 23 41 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 56 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E7141 Primary carnitine deficiency 23 23 23 41 Yes Yes Yes Yes


E7142 Carnitine deficiency due to inborn errors of metabolism 23 23 23 41 Yes Yes Yes Yes
E7143 Iatrogenic carnitine deficiency 23 23 23 41 Yes Yes Yes Yes
E71440 Ruvalcaba-Myhre-Smith syndrome 23 23 23 41 Yes Yes Yes Yes
E71448 Other secondary carnitine deficiency 23 23 23 41 Yes Yes Yes Yes
E7150 Peroxisomal disorder, unspecified 23 23 23 41 Yes Yes Yes Yes
E71510 Zellweger syndrome 23 23 23 41 Yes Yes Yes Yes
E71511 Neonatal adrenoleukodystrophy 23 23 23 41 Yes Yes Yes Yes
E71518 Other disorders of peroxisome biogenesis 23 23 23 41 Yes Yes Yes Yes
E71520 Childhood cerebral X-linked adrenoleukodystrophy 23 23 23 41 Yes Yes Yes Yes
E71521 Adolescent X-linked adrenoleukodystrophy 23 23 23 41 Yes Yes Yes Yes
E71522 Adrenomyeloneuropathy 23 23 23 41 Yes Yes Yes Yes
E71528 Other X-linked adrenoleukodystrophy 23 23 23 41 Yes Yes Yes Yes
E71529 X-linked adrenoleukodystrophy, unspecified type 23 23 23 41 Yes Yes Yes Yes
E7153 Other group 2 peroxisomal disorders 23 23 23 41 Yes Yes Yes Yes
E71540 Rhizomelic chondrodysplasia punctata 23 23 23 41 Yes Yes Yes Yes
E71541 Zellweger-like syndrome 23 23 23 41 Yes Yes Yes Yes
E71542 Other group 3 peroxisomal disorders 23 23 23 41 Yes Yes Yes Yes
E71548 Other peroxisomal disorders 23 23 23 41 Yes Yes Yes Yes
E7200 Disorders of amino-acid transport, unspecified 23 23 23 41 Yes Yes Yes Yes
E7201 Cystinuria 23 23 23 41 Yes Yes Yes Yes
E7202 Hartnup's disease 23 23 23 41 Yes Yes Yes Yes
E7203 Lowe's syndrome 23 23 23 41 Yes Yes Yes Yes
E7204 Cystinosis 23 23 23 41 Yes Yes Yes Yes
E7209 Other disorders of amino-acid transport 23 23 23 41 Yes Yes Yes Yes
E7210 Disorders of sulfur-bearing amino-acid metabolism, unspecified 23 23 23 41 Yes Yes Yes Yes
E7211 Homocystinuria 23 23 23 41 Yes Yes Yes Yes
E7212 Methylenetetrahydrofolate reductase deficiency 23 23 23 41 Yes Yes Yes Yes
E7219 Other disorders of sulfur-bearing amino-acid metabolism 23 23 23 41 Yes Yes Yes Yes
E7220 Disorder of urea cycle metabolism, unspecified 23 23 23 41 Yes Yes Yes Yes
E7221 Argininemia 23 23 23 41 Yes Yes Yes Yes
E7222 Arginosuccinic aciduria 23 23 23 41 Yes Yes Yes Yes
E7223 Citrullinemia 23 23 23 41 Yes Yes Yes Yes
E7229 Other disorders of urea cycle metabolism 23 23 23 41 Yes Yes Yes Yes
E723 Disorders of lysine and hydroxylysine metabolism 23 23 23 41 Yes Yes Yes Yes
E724 Disorders of ornithine metabolism 23 23 23 41 Yes Yes Yes Yes
E7250 Disorder of glycine metabolism, unspecified 23 23 23 41 Yes Yes Yes Yes
E7251 Non-ketotic hyperglycinemia 23 23 23 41 Yes Yes Yes Yes
E7252 Trimethylaminuria 23 23 23 41 Yes Yes Yes Yes
E7253 Primary hyperoxaluria 23 23 23 41 Yes Yes Yes Yes
E7259 Other disorders of glycine metabolism 23 23 23 41 Yes Yes Yes Yes
E7281 Disorders of gamma aminobutyric acid metabolism 23 23 23 41 Yes Yes Yes Yes
E7289 Other specified disorders of amino-acid metabolism 23 23 23 41 Yes Yes Yes Yes
E729 Disorder of amino-acid metabolism, unspecified 23 23 23 41 Yes Yes Yes Yes
E7400 Glycogen storage disease, unspecified 23 23 23 41 Yes Yes Yes Yes
E7401 von Gierke disease 23 23 23 41 Yes Yes Yes Yes
E7402 Pompe disease 23 23 23 41 Yes Yes Yes Yes
E7403 Cori disease 23 23 23 41 Yes Yes Yes Yes
E7404 McArdle disease 23 23 23 41 Yes Yes Yes Yes
E7409 Other glycogen storage disease 23 23 23 41 Yes Yes Yes Yes
E7420 Disorders of galactose metabolism, unspecified 23 23 23 41 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 57 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E7421 Galactosemia 23 23 23 41 Yes Yes Yes Yes


E7429 Other disorders of galactose metabolism 23 23 23 41 Yes Yes Yes Yes
E744 Disorders of pyruvate metabolism and gluconeogenesis 23 23 23 41 Yes Yes Yes Yes
E748 Other specified disorders of carbohydrate metabolism 23 23 23 41 Yes Yes Yes Yes
E74810 Glucose transporter protein type 1 deficiency 23 23 23 41 Yes Yes Yes Yes
E74818 Other disorders of glucose transport 23 23 23 41 Yes Yes Yes Yes
E74819 Disorders of glucose transport, unspecified 23 23 23 41 Yes Yes Yes Yes
E7489 Other specified disorders of carbohydrate metabolism 23 23 23 41 Yes Yes Yes Yes
E749 Disorder of carbohydrate metabolism, unspecified 23 23 23 41 Yes Yes Yes Yes
E7500 GM2 gangliosidosis, unspecified 52 52 112 Yes No Yes Yes
E7501 Sandhoff disease 52 52 112 Yes No Yes Yes
E7502 Tay-Sachs disease 52 52 112 Yes No Yes Yes
E7509 Other GM2 gangliosidosis 52 52 112 Yes No Yes Yes
E7510 Unspecified gangliosidosis 52 52 112 Yes No Yes Yes
E7511 Mucolipidosis IV 52 52 112 Yes No Yes Yes
E7519 Other gangliosidosis 52 52 112 Yes No Yes Yes
E7521 Fabry (-Anderson) disease 23 23 23 41 Yes Yes Yes Yes
E7522 Gaucher disease 23 23 23 41 Yes Yes Yes Yes
E7523 Krabbe disease 52 52 112 Yes No Yes Yes
E75240 Niemann-Pick disease type A 23 23 23 41 Yes Yes Yes Yes
E75241 Niemann-Pick disease type B 23 23 23 41 Yes Yes Yes Yes
E75242 Niemann-Pick disease type C 23 23 23 41 Yes Yes Yes Yes
E75243 Niemann-Pick disease type D 23 23 23 41 Yes Yes Yes Yes
E75248 Other Niemann-Pick disease 23 23 23 41 Yes Yes Yes Yes
E75249 Niemann-Pick disease, unspecified 23 23 23 41 Yes Yes Yes Yes
E7525 Metachromatic leukodystrophy 52 52 112 Yes No Yes Yes
E7526 Sulfatase deficiency 52 52 112 Yes No Yes Yes
E7529 Other sphingolipidosis 52 52 112 Yes No Yes Yes
E753 Sphingolipidosis, unspecified 23 23 23 41 Yes Yes Yes Yes
E754 Neuronal ceroid lipofuscinosis 52 52 112 Yes No Yes Yes
E755 Other lipid storage disorders 45 No No No Yes
E756 Lipid storage disorder, unspecified 45 No No No Yes
E7601 Hurler's syndrome 23 23 23 41 Yes Yes Yes Yes
E7602 Hurler-Scheie syndrome 23 23 23 41 Yes Yes Yes Yes
E7603 Scheie's syndrome 23 23 23 41 Yes Yes Yes Yes
E761 Mucopolysaccharidosis, type II 23 23 23 41 Yes Yes Yes Yes
E76210 Morquio A mucopolysaccharidoses 23 23 23 41 Yes Yes Yes Yes
E76211 Morquio B mucopolysaccharidoses 23 23 23 41 Yes Yes Yes Yes
E76219 Morquio mucopolysaccharidoses, unspecified 23 23 23 41 Yes Yes Yes Yes
E7622 Sanfilippo mucopolysaccharidoses 23 23 23 41 Yes Yes Yes Yes
E7629 Other mucopolysaccharidoses 23 23 23 41 Yes Yes Yes Yes
E763 Mucopolysaccharidosis, unspecified 23 23 23 41 Yes Yes Yes Yes
E768 Other disorders of glucosaminoglycan metabolism 23 23 23 41 Yes Yes Yes Yes
E769 Glucosaminoglycan metabolism disorder, unspecified 23 23 23 41 Yes Yes Yes Yes
E770 Defects in post-translational modification of lysosomal enzymes 23 23 23 41 Yes Yes Yes Yes
E771 Defects in glycoprotein degradation 23 23 23 41 Yes Yes Yes Yes
E778 Other disorders of glycoprotein metabolism 23 23 23 41 Yes Yes Yes Yes
E779 Disorder of glycoprotein metabolism, unspecified 23 23 23 41 Yes Yes Yes Yes
E7800 Pure hypercholesterolemia, unspecified 45 No No No Yes
E7801 Familial hypercholesterolemia 45 No No No Yes
E781 Pure hyperglyceridemia 45 No No No Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 58 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E782 Mixed hyperlipidemia 45 No No No Yes


E783 Hyperchylomicronemia 45 No No No Yes
E7841 Elevated Lipoprotein(a) 45 No No No Yes
E7849 Other hyperlipidemia 45 No No No Yes
E785 Hyperlipidemia, unspecified 45 No No No Yes
E786 Lipoprotein deficiency 45 No No No Yes
E7870 Disorder of bile acid and cholesterol metabolism, unspecified 45 No No No Yes
E7879 Other disorders of bile acid and cholesterol metabolism 45 No No No Yes
E7881 Lipoid dermatoarthritis 45 No No No Yes
E7889 Other lipoprotein metabolism disorders 45 No No No Yes
E789 Disorder of lipoprotein metabolism, unspecified 45 No No No Yes
E791 Lesch-Nyhan syndrome 23 23 23 41 Yes Yes Yes Yes
E792 Myoadenylate deaminase deficiency 23 23 23 41 Yes Yes Yes Yes
E798 Other disorders of purine and pyrimidine metabolism 23 23 23 41 Yes Yes Yes Yes
E799 Disorder of purine and pyrimidine metabolism, unspecified 23 23 23 41 Yes Yes Yes Yes
E800 Hereditary erythropoietic porphyria 23 23 23 41 Yes Yes Yes Yes
E801 Porphyria cutanea tarda 23 23 23 41 Yes Yes Yes Yes
E8020 Unspecified porphyria 23 23 23 41 Yes Yes Yes Yes
E8021 Acute intermittent (hepatic) porphyria 23 23 23 41 Yes Yes Yes Yes
E8029 Other porphyria 23 23 23 41 Yes Yes Yes Yes
E803 Defects of catalase and peroxidase 23 23 23 41 Yes Yes Yes Yes
E8300 Disorder of copper metabolism, unspecified 41 No No No Yes
E8301 Wilson's disease 41 No No No Yes
E8309 Other disorders of copper metabolism 41 No No No Yes
E8310 Disorder of iron metabolism, unspecified 41 No No No Yes
E83110 Hereditary hemochromatosis 23 23 23 41 Yes Yes Yes Yes
E83118 Other hemochromatosis 41 No No No Yes
E83119 Hemochromatosis, unspecified 41 No No No Yes
E8319 Other disorders of iron metabolism 41 No No No Yes
E8330 Disorder of phosphorus metabolism, unspecified 41 No No No Yes
E8331 Familial hypophosphatemia 41 No No No Yes
E8332 Hereditary vitamin D-dependent rickets (type 1) (type 2) 41 No No No Yes
E8339 Other disorders of phosphorus metabolism 41 No No No Yes
E840 Cystic fibrosis with pulmonary manifestations 110 110 110 225 Yes Yes Yes Yes
E8411 Meconium ileus in cystic fibrosis 110 110 110 225 Yes Yes Yes Yes
E8419 Cystic fibrosis with other intestinal manifestations 110 110 110 225 Yes Yes Yes Yes
E848 Cystic fibrosis with other manifestations 110 110 110 225 Yes Yes Yes Yes
E849 Cystic fibrosis, unspecified 110 110 110 225 Yes Yes Yes Yes
E850 Non-neuropathic heredofamilial amyloidosis 23 23 23 Yes Yes Yes No
E851 Neuropathic heredofamilial amyloidosis 23 23 23 Yes Yes Yes No
E852 Heredofamilial amyloidosis, unspecified 23 23 23 Yes Yes Yes No
E853 Secondary systemic amyloidosis 23 23 23 Yes Yes Yes No
E854 Organ-limited amyloidosis 23 23 23 Yes Yes Yes No
E8581 Light chain (AL) amyloidosis 23 23 23 Yes Yes Yes No
E8582 Wild-type transthyretin-related (ATTR) amyloidosis 23 23 23 Yes Yes Yes No
E8589 Other amyloidosis 23 23 23 Yes Yes Yes No
E859 Amyloidosis, unspecified 23 23 23 Yes Yes Yes No
E8801 Alpha-1-antitrypsin deficiency 23 23 23 40 Yes Yes Yes Yes
E882 Lipomatosis, not elsewhere classified 45 No No No Yes
E8840 Mitochondrial metabolism disorder, unspecified 23 23 23 41 Yes Yes Yes Yes
E8841 MELAS syndrome 23 23 23 41 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 59 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

E8842 MERRF syndrome 23 23 23 41 Yes Yes Yes Yes


E8849 Other mitochondrial metabolism disorders 23 23 23 41 Yes Yes Yes Yes
E8889 Other specified metabolic disorders 23 23 23 41 Yes Yes Yes Yes
E890 Postprocedural hypothyroidism 42 No No No Yes
E892 Postprocedural hypoparathyroidism 23 23 23 41 Yes Yes Yes Yes
E893 Postprocedural hypopituitarism 23 23 23 41 Yes Yes Yes Yes
E896 Postprocedural adrenocortical (-medullary) hypofunction 23 23 23 41 Yes Yes Yes Yes
F0150 Vascular dementia without behavioral disturbance 52 52 112 Yes No Yes Yes
F0151 Vascular dementia with behavioral disturbance 51 51 112 Yes No Yes Yes
F0280 Dementia in other diseases classified elsewhere without behavioral disturbance 52 52 112 Yes No Yes Yes
F0281 Dementia in other diseases classified elsewhere with behavioral disturbance 51 51 112 Yes No Yes Yes
F0390 Unspecified dementia without behavioral disturbance 52 52 112 Yes No Yes Yes
F0391 Unspecified dementia with behavioral disturbance 51 51 112 Yes No Yes Yes
F04 Amnestic disorder due to known physiological condition 52 52 112 Yes No Yes Yes
F10120 Alcohol abuse with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F10121 Alcohol abuse with intoxication delirium 55 55 55 Yes Yes Yes No
F10129 Alcohol abuse with intoxication, unspecified 55 55 55 Yes Yes Yes No
F10130 Alcohol abuse with withdrawal, uncomplicated 55 55 55 Yes Yes Yes No
F10131 Alcohol abuse with withdrawal delirium 54 54 54 Yes Yes Yes No
F10132 Alcohol abuse with withdrawal with perceptual disturbance 54 54 54 Yes Yes Yes No
F10139 Alcohol abuse with withdrawal, unspecified 55 55 55 Yes Yes Yes No
F1014 Alcohol abuse with alcohol-induced mood disorder 55 55 55 Yes Yes Yes No
F10150 Alcohol abuse with alcohol-induced psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F10151 Alcohol abuse with alcohol-induced psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F10159 Alcohol abuse with alcohol-induced psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F10180 Alcohol abuse with alcohol-induced anxiety disorder 55 55 55 Yes Yes Yes No
F10181 Alcohol abuse with alcohol-induced sexual dysfunction 55 55 55 Yes Yes Yes No
F10182 Alcohol abuse with alcohol-induced sleep disorder 55 55 55 Yes Yes Yes No
F10188 Alcohol abuse with other alcohol-induced disorder 55 55 55 Yes Yes Yes No
F1019 Alcohol abuse with unspecified alcohol-induced disorder 55 55 55 Yes Yes Yes No
F1020 Alcohol dependence, uncomplicated 55 55 55 Yes Yes Yes No
F1021 Alcohol dependence, in remission 55 55 55 Yes Yes Yes No
F10220 Alcohol dependence with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F10221 Alcohol dependence with intoxication delirium 55 55 55 Yes Yes Yes No
F10229 Alcohol dependence with intoxication, unspecified 55 55 55 Yes Yes Yes No
F10230 Alcohol dependence with withdrawal, uncomplicated 55 55 55 Yes Yes Yes No
F10231 Alcohol dependence with withdrawal delirium 54 54 54 Yes Yes Yes No
F10232 Alcohol dependence with withdrawal with perceptual disturbance 54 54 54 Yes Yes Yes No
F10239 Alcohol dependence with withdrawal, unspecified 55 55 55 Yes Yes Yes No
F1024 Alcohol dependence with alcohol-induced mood disorder 55 55 55 Yes Yes Yes No
F10250 Alcohol dependence with alcohol-induced psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F10251 Alcohol dependence with alcohol-induced psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F10259 Alcohol dependence with alcohol-induced psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F1026 Alcohol dependence with alcohol-induced persisting amnestic disorder 54 54 54 Yes Yes Yes No
F1027 Alcohol dependence with alcohol-induced persisting dementia 54 54 54 Yes Yes Yes No
F10280 Alcohol dependence with alcohol-induced anxiety disorder 55 55 55 Yes Yes Yes No
F10281 Alcohol dependence with alcohol-induced sexual dysfunction 55 55 55 Yes Yes Yes No
F10282 Alcohol dependence with alcohol-induced sleep disorder 55 55 55 Yes Yes Yes No
F10288 Alcohol dependence with other alcohol-induced disorder 55 55 55 Yes Yes Yes No
F1029 Alcohol dependence with unspecified alcohol-induced disorder 55 55 55 Yes Yes Yes No
F10920 Alcohol use, unspecified with intoxication, uncomplicated 55 55 55 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 60 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

F10921 Alcohol use, unspecified with intoxication delirium 55 55 55 Yes Yes Yes No
F10929 Alcohol use, unspecified with intoxication, unspecified 55 55 55 Yes Yes Yes No
F10930 Alcohol use, unspecified with withdrawal, uncomplicated 55 55 55 Yes Yes Yes No
F10931 Alcohol use, unspecified with withdrawal delirium 54 54 54 Yes Yes Yes No
F10932 Alcohol use, unspecified with withdrawal with perceptual disturbance 54 54 54 Yes Yes Yes No
F10939 Alcohol use, unspecified with withdrawal, unspecified 55 55 55 Yes Yes Yes No
F1094 Alcohol use, unspecified with alcohol-induced mood disorder 55 55 55 Yes Yes Yes No
F10950 Alcohol use, unspecified with alcohol-induced psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F10951 Alcohol use, unspecified with alcohol-induced psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F10959 Alcohol use, unspecified with alcohol-induced psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F1096 Alcohol use, unspecified with alcohol-induced persisting amnestic disorder 54 54 54 Yes Yes Yes No
F1097 Alcohol use, unspecified with alcohol-induced persisting dementia 54 54 54 Yes Yes Yes No
F10980 Alcohol use, unspecified with alcohol-induced anxiety disorder 55 55 55 Yes Yes Yes No
F10981 Alcohol use, unspecified with alcohol-induced sexual dysfunction 55 55 55 Yes Yes Yes No
F10982 Alcohol use, unspecified with alcohol-induced sleep disorder 55 55 55 Yes Yes Yes No
F10988 Alcohol use, unspecified with other alcohol-induced disorder 55 55 55 Yes Yes Yes No
F1099 Alcohol use, unspecified with unspecified alcohol-induced disorder 55 55 55 Yes Yes Yes No
F1110 Opioid abuse, uncomplicated 56 No No Yes No
F1111 Opioid abuse, in remission 56 No No Yes No
F11120 Opioid abuse with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F11121 Opioid abuse with intoxication delirium 55 55 55 Yes Yes Yes No
F11122 Opioid abuse with intoxication with perceptual disturbance 55 55 55 Yes Yes Yes No
F11129 Opioid abuse with intoxication, unspecified 55 55 55 Yes Yes Yes No
F1113 Opioid abuse with withdrawal 55 55 55 Yes Yes Yes No
F1114 Opioid abuse with opioid-induced mood disorder 55 55 55 Yes Yes Yes No
F11150 Opioid abuse with opioid-induced psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F11151 Opioid abuse with opioid-induced psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F11159 Opioid abuse with opioid-induced psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F11181 Opioid abuse with opioid-induced sexual dysfunction 55 55 55 Yes Yes Yes No
F11182 Opioid abuse with opioid-induced sleep disorder 55 55 55 Yes Yes Yes No
F11188 Opioid abuse with other opioid-induced disorder 55 55 55 Yes Yes Yes No
F1119 Opioid abuse with unspecified opioid-induced disorder 55 55 55 Yes Yes Yes No
F1120 Opioid dependence, uncomplicated 55 55 55 Yes Yes Yes No
F1121 Opioid dependence, in remission 55 55 55 Yes Yes Yes No
F11220 Opioid dependence with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F11221 Opioid dependence with intoxication delirium 55 55 55 Yes Yes Yes No
F11222 Opioid dependence with intoxication with perceptual disturbance 55 55 55 Yes Yes Yes No
F11229 Opioid dependence with intoxication, unspecified 55 55 55 Yes Yes Yes No
F1123 Opioid dependence with withdrawal 55 55 55 Yes Yes Yes No
F1124 Opioid dependence with opioid-induced mood disorder 55 55 55 Yes Yes Yes No
F11250 Opioid dependence with opioid-induced psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F11251 Opioid dependence with opioid-induced psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F11259 Opioid dependence with opioid-induced psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F11281 Opioid dependence with opioid-induced sexual dysfunction 55 55 55 Yes Yes Yes No
F11282 Opioid dependence with opioid-induced sleep disorder 55 55 55 Yes Yes Yes No
F11288 Opioid dependence with other opioid-induced disorder 55 55 55 Yes Yes Yes No
F1129 Opioid dependence with unspecified opioid-induced disorder 55 55 55 Yes Yes Yes No
F11920 Opioid use, unspecified with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F11921 Opioid use, unspecified with intoxication delirium 55 55 55 Yes Yes Yes No
F11922 Opioid use, unspecified with intoxication with perceptual disturbance 55 55 55 Yes Yes Yes No
F11929 Opioid use, unspecified with intoxication, unspecified 55 55 55 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 61 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

F1193 Opioid use, unspecified with withdrawal 55 55 55 Yes Yes Yes No


F1194 Opioid use, unspecified with opioid-induced mood disorder 55 55 55 Yes Yes Yes No
F11950 Opioid use, unspecified with opioid-induced psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F11951 Opioid use, unspecified with opioid-induced psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F11959 Opioid use, unspecified with opioid-induced psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F11981 Opioid use, unspecified with opioid-induced sexual dysfunction 55 55 55 Yes Yes Yes No
F11982 Opioid use, unspecified with opioid-induced sleep disorder 55 55 55 Yes Yes Yes No
F11988 Opioid use, unspecified with other opioid-induced disorder 55 55 55 Yes Yes Yes No
F1199 Opioid use, unspecified with unspecified opioid-induced disorder 55 55 55 Yes Yes Yes No
F12120 Cannabis abuse with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F12121 Cannabis abuse with intoxication delirium 55 55 55 Yes Yes Yes No
F12122 Cannabis abuse with intoxication with perceptual disturbance 55 55 55 Yes Yes Yes No
F12129 Cannabis abuse with intoxication, unspecified 55 55 55 Yes Yes Yes No
F1213 Cannabis abuse with withdrawal 55 55 55 Yes Yes Yes No
F12150 Cannabis abuse with psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F12151 Cannabis abuse with psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F12159 Cannabis abuse with psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F12180 Cannabis abuse with cannabis-induced anxiety disorder 55 55 55 Yes Yes Yes No
F12188 Cannabis abuse with other cannabis-induced disorder 55 55 55 Yes Yes Yes No
F1219 Cannabis abuse with unspecified cannabis-induced disorder 55 55 55 Yes Yes Yes No
F1220 Cannabis dependence, uncomplicated 55 55 55 Yes Yes Yes No
F1221 Cannabis dependence, in remission 55 55 55 Yes Yes Yes No
F12220 Cannabis dependence with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F12221 Cannabis dependence with intoxication delirium 55 55 55 Yes Yes Yes No
F12222 Cannabis dependence with intoxication with perceptual disturbance 55 55 55 Yes Yes Yes No
F12229 Cannabis dependence with intoxication, unspecified 55 55 55 Yes Yes Yes No
F1223 Cannabis dependence with withdrawal 55 55 55 Yes Yes Yes No
F12250 Cannabis dependence with psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F12251 Cannabis dependence with psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F12259 Cannabis dependence with psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F12280 Cannabis dependence with cannabis-induced anxiety disorder 55 55 55 Yes Yes Yes No
F12288 Cannabis dependence with other cannabis-induced disorder 55 55 55 Yes Yes Yes No
F1229 Cannabis dependence with unspecified cannabis-induced disorder 55 55 55 Yes Yes Yes No
F12920 Cannabis use, unspecified with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F12921 Cannabis use, unspecified with intoxication delirium 55 55 55 Yes Yes Yes No
F12922 Cannabis use, unspecified with intoxication with perceptual disturbance 55 55 55 Yes Yes Yes No
F12929 Cannabis use, unspecified with intoxication, unspecified 55 55 55 Yes Yes Yes No
F1293 Cannabis use, unspecified with withdrawal 55 55 55 Yes Yes Yes No
F12950 Cannabis use, unspecified with psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F12951 Cannabis use, unspecified with psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F12959 Cannabis use, unspecified with psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F12980 Cannabis use, unspecified with anxiety disorder 55 55 55 Yes Yes Yes No
F12988 Cannabis use, unspecified with other cannabis-induced disorder 55 55 55 Yes Yes Yes No
F1299 Cannabis use, unspecified with unspecified cannabis-induced disorder 55 55 55 Yes Yes Yes No
F1310 Sedative, hypnotic or anxiolytic abuse, uncomplicated 56 No No Yes No
F1311 Sedative, hypnotic or anxiolytic abuse, in remission 56 No No Yes No
F13120 Sedative, hypnotic or anxiolytic abuse with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F13121 Sedative, hypnotic or anxiolytic abuse with intoxication delirium 55 55 55 Yes Yes Yes No
F13129 Sedative, hypnotic or anxiolytic abuse with intoxication, unspecified 55 55 55 Yes Yes Yes No
F13130 Sedative, hypnotic or anxiolytic abuse with withdrawal, uncomplicated 55 55 55 Yes Yes Yes No
F13131 Sedative, hypnotic or anxiolytic abuse with withdrawal delirium 54 54 54 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 62 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

F13132 Sedative, hypnotic or anxiolytic abuse with withdrawal with perceptual disturbance 54 54 54 Yes Yes Yes No
F13139 Sedative, hypnotic or anxiolytic abuse with withdrawal, unspecified 55 55 55 Yes Yes Yes No
F1314 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced mood disorder 55 55 55 Yes Yes Yes No
F13150 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic 54 54 54 Yes Yes Yes No
disorder with delusions
F13151 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic 54 54 54 Yes Yes Yes No
disorder with hallucinations
F13159 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic 54 54 54 Yes Yes Yes No
disorder, unspecified
F13180 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced anxiety disorder 55 55 55 Yes Yes Yes No
F13181 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sexual 55 55 55 Yes Yes Yes No
dysfunction
F13182 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sleep disorder 55 55 55 Yes Yes Yes No
F13188 Sedative, hypnotic or anxiolytic abuse with other sedative, hypnotic or anxiolytic-induced disorder 55 55 55 Yes Yes Yes No
F1319 Sedative, hypnotic or anxiolytic abuse with unspecified sedative, hypnotic or anxiolytic-induced 55 55 55 Yes Yes Yes No
disorder
F1320 Sedative, hypnotic or anxiolytic dependence, uncomplicated 55 55 55 Yes Yes Yes No
F1321 Sedative, hypnotic or anxiolytic dependence, in remission 55 55 55 Yes Yes Yes No
F13220 Sedative, hypnotic or anxiolytic dependence with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F13221 Sedative, hypnotic or anxiolytic dependence with intoxication delirium 55 55 55 Yes Yes Yes No
F13229 Sedative, hypnotic or anxiolytic dependence with intoxication, unspecified 55 55 55 Yes Yes Yes No
F13230 Sedative, hypnotic or anxiolytic dependence with withdrawal, uncomplicated 55 55 55 Yes Yes Yes No
F13231 Sedative, hypnotic or anxiolytic dependence with withdrawal delirium 54 54 54 Yes Yes Yes No
F13232 Sedative, hypnotic or anxiolytic dependence with withdrawal with perceptual disturbance 54 54 54 Yes Yes Yes No
F13239 Sedative, hypnotic or anxiolytic dependence with withdrawal, unspecified 55 55 55 Yes Yes Yes No
F1324 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced mood 55 55 55 Yes Yes Yes No
disorder
F13250 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic 54 54 54 Yes Yes Yes No
disorder with delusions
F13251 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic 54 54 54 Yes Yes Yes No
disorder with hallucinations
F13259 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic 54 54 54 Yes Yes Yes No
disorder, unspecified
F1326 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting 54 54 54 Yes Yes Yes No
amnestic disorder
F1327 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting 54 54 54 Yes Yes Yes No
dementia
F13280 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced anxiety 55 55 55 Yes Yes Yes No
disorder
F13281 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sexual 55 55 55 Yes Yes Yes No
dysfunction
F13282 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep 55 55 55 Yes Yes Yes No
disorder
F13288 Sedative, hypnotic or anxiolytic dependence with other sedative, hypnotic or anxiolytic-induced 55 55 55 Yes Yes Yes No
disorder
F1329 Sedative, hypnotic or anxiolytic dependence with unspecified sedative, hypnotic or anxiolytic- 55 55 55 Yes Yes Yes No
induced disorder
F13920 Sedative, hypnotic or anxiolytic use, unspecified with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F13921 Sedative, hypnotic or anxiolytic use, unspecified with intoxication delirium 55 55 55 Yes Yes Yes No
F13929 Sedative, hypnotic or anxiolytic use, unspecified with intoxication, unspecified 55 55 55 Yes Yes Yes No
F13930 Sedative, hypnotic or anxiolytic use, unspecified with withdrawal, uncomplicated 55 55 55 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 63 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

F13931 Sedative, hypnotic or anxiolytic use, unspecified with withdrawal delirium 54 54 54 Yes Yes Yes No
F13932 Sedative, hypnotic or anxiolytic use, unspecified with withdrawal with perceptual disturbances 54 54 54 Yes Yes Yes No
F13939 Sedative, hypnotic or anxiolytic use, unspecified with withdrawal, unspecified 55 55 55 Yes Yes Yes No
F1394 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced mood 55 55 55 Yes Yes Yes No
disorder
F13950 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced 54 54 54 Yes Yes Yes No
psychotic disorder with delusions
F13951 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced 54 54 54 Yes Yes Yes No
psychotic disorder with hallucinations
F13959 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced 54 54 54 Yes Yes Yes No
psychotic disorder, unspecified
F1396 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced 54 54 54 Yes Yes Yes No
persisting amnestic disorder
F1397 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced 54 54 54 Yes Yes Yes No
persisting dementia
F13980 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced anxiety 55 55 55 Yes Yes Yes No
disorder
F13981 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced sexual 55 55 55 Yes Yes Yes No
dysfunction
F13982 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced sleep 55 55 55 Yes Yes Yes No
disorder
F13988 Sedative, hypnotic or anxiolytic use, unspecified with other sedative, hypnotic or anxiolytic-induced 55 55 55 Yes Yes Yes No
disorder
F1399 Sedative, hypnotic or anxiolytic use, unspecified with unspecified sedative, hypnotic or anxiolytic- 55 55 55 Yes Yes Yes No
induced disorder
F1410 Cocaine abuse, uncomplicated 56 No No Yes No
F1411 Cocaine abuse, in remission 56 No No Yes No
F14120 Cocaine abuse with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F14121 Cocaine abuse with intoxication with delirium 55 55 55 Yes Yes Yes No
F14122 Cocaine abuse with intoxication with perceptual disturbance 55 55 55 Yes Yes Yes No
F14129 Cocaine abuse with intoxication, unspecified 55 55 55 Yes Yes Yes No
F1413 Cocaine abuse, unspecified with withdrawal 55 55 55 Yes Yes Yes No
F1414 Cocaine abuse with cocaine-induced mood disorder 55 55 55 Yes Yes Yes No
F14150 Cocaine abuse with cocaine-induced psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F14151 Cocaine abuse with cocaine-induced psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F14159 Cocaine abuse with cocaine-induced psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F14180 Cocaine abuse with cocaine-induced anxiety disorder 55 55 55 Yes Yes Yes No
F14181 Cocaine abuse with cocaine-induced sexual dysfunction 55 55 55 Yes Yes Yes No
F14182 Cocaine abuse with cocaine-induced sleep disorder 55 55 55 Yes Yes Yes No
F14188 Cocaine abuse with other cocaine-induced disorder 55 55 55 Yes Yes Yes No
F1419 Cocaine abuse with unspecified cocaine-induced disorder 55 55 55 Yes Yes Yes No
F1420 Cocaine dependence, uncomplicated 55 55 55 Yes Yes Yes No
F1421 Cocaine dependence, in remission 55 55 55 Yes Yes Yes No
F14220 Cocaine dependence with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F14221 Cocaine dependence with intoxication delirium 55 55 55 Yes Yes Yes No
F14222 Cocaine dependence with intoxication with perceptual disturbance 55 55 55 Yes Yes Yes No
F14229 Cocaine dependence with intoxication, unspecified 55 55 55 Yes Yes Yes No
F1423 Cocaine dependence with withdrawal 55 55 55 Yes Yes Yes No
F1424 Cocaine dependence with cocaine-induced mood disorder 55 55 55 Yes Yes Yes No
F14250 Cocaine dependence with cocaine-induced psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F14251 Cocaine dependence with cocaine-induced psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 64 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

F14259 Cocaine dependence with cocaine-induced psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F14280 Cocaine dependence with cocaine-induced anxiety disorder 55 55 55 Yes Yes Yes No
F14281 Cocaine dependence with cocaine-induced sexual dysfunction 55 55 55 Yes Yes Yes No
F14282 Cocaine dependence with cocaine-induced sleep disorder 55 55 55 Yes Yes Yes No
F14288 Cocaine dependence with other cocaine-induced disorder 55 55 55 Yes Yes Yes No
F1429 Cocaine dependence with unspecified cocaine-induced disorder 55 55 55 Yes Yes Yes No
F14920 Cocaine use, unspecified with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F14921 Cocaine use, unspecified with intoxication delirium 55 55 55 Yes Yes Yes No
F14922 Cocaine use, unspecified with intoxication with perceptual disturbance 55 55 55 Yes Yes Yes No
F14929 Cocaine use, unspecified with intoxication, unspecified 55 55 55 Yes Yes Yes No
F1493 Cocaine use, unspecified with withdrawal 55 55 55 Yes Yes Yes No
F1494 Cocaine use, unspecified with cocaine-induced mood disorder 55 55 55 Yes Yes Yes No
F14950 Cocaine use, unspecified with cocaine-induced psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F14951 Cocaine use, unspecified with cocaine-induced psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F14959 Cocaine use, unspecified with cocaine-induced psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F14980 Cocaine use, unspecified with cocaine-induced anxiety disorder 55 55 55 Yes Yes Yes No
F14981 Cocaine use, unspecified with cocaine-induced sexual dysfunction 55 55 55 Yes Yes Yes No
F14982 Cocaine use, unspecified with cocaine-induced sleep disorder 55 55 55 Yes Yes Yes No
F14988 Cocaine use, unspecified with other cocaine-induced disorder 55 55 55 Yes Yes Yes No
F1499 Cocaine use, unspecified with unspecified cocaine-induced disorder 55 55 55 Yes Yes Yes No
F1510 Other stimulant abuse, uncomplicated 56 No No Yes No
F1511 Other stimulant abuse, in remission 56 No No Yes No
F15120 Other stimulant abuse with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F15121 Other stimulant abuse with intoxication delirium 55 55 55 Yes Yes Yes No
F15122 Other stimulant abuse with intoxication with perceptual disturbance 55 55 55 Yes Yes Yes No
F15129 Other stimulant abuse with intoxication, unspecified 55 55 55 Yes Yes Yes No
F1513 Other stimulant abuse with withdrawal 55 55 55 Yes Yes Yes No
F1514 Other stimulant abuse with stimulant-induced mood disorder 55 55 55 Yes Yes Yes No
F15150 Other stimulant abuse with stimulant-induced psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F15151 Other stimulant abuse with stimulant-induced psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F15159 Other stimulant abuse with stimulant-induced psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F15180 Other stimulant abuse with stimulant-induced anxiety disorder 55 55 55 Yes Yes Yes No
F15181 Other stimulant abuse with stimulant-induced sexual dysfunction 55 55 55 Yes Yes Yes No
F15182 Other stimulant abuse with stimulant-induced sleep disorder 55 55 55 Yes Yes Yes No
F15188 Other stimulant abuse with other stimulant-induced disorder 55 55 55 Yes Yes Yes No
F1519 Other stimulant abuse with unspecified stimulant-induced disorder 55 55 55 Yes Yes Yes No
F1520 Other stimulant dependence, uncomplicated 55 55 55 Yes Yes Yes No
F1521 Other stimulant dependence, in remission 55 55 55 Yes Yes Yes No
F15220 Other stimulant dependence with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F15221 Other stimulant dependence with intoxication delirium 55 55 55 Yes Yes Yes No
F15222 Other stimulant dependence with intoxication with perceptual disturbance 55 55 55 Yes Yes Yes No
F15229 Other stimulant dependence with intoxication, unspecified 55 55 55 Yes Yes Yes No
F1523 Other stimulant dependence with withdrawal 55 55 55 Yes Yes Yes No
F1524 Other stimulant dependence with stimulant-induced mood disorder 55 55 55 Yes Yes Yes No
F15250 Other stimulant dependence with stimulant-induced psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F15251 Other stimulant dependence with stimulant-induced psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F15259 Other stimulant dependence with stimulant-induced psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F15280 Other stimulant dependence with stimulant-induced anxiety disorder 55 55 55 Yes Yes Yes No
F15281 Other stimulant dependence with stimulant-induced sexual dysfunction 55 55 55 Yes Yes Yes No
F15282 Other stimulant dependence with stimulant-induced sleep disorder 55 55 55 Yes Yes Yes No
F15288 Other stimulant dependence with other stimulant-induced disorder 55 55 55 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 65 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

F1529 Other stimulant dependence with unspecified stimulant-induced disorder 55 55 55 Yes Yes Yes No
F15920 Other stimulant use, unspecified with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F15921 Other stimulant use, unspecified with intoxication delirium 55 55 55 Yes Yes Yes No
F15922 Other stimulant use, unspecified with intoxication with perceptual disturbance 55 55 55 Yes Yes Yes No
F15929 Other stimulant use, unspecified with intoxication, unspecified 55 55 55 Yes Yes Yes No
F1593 Other stimulant use, unspecified with withdrawal 55 55 55 Yes Yes Yes No
F1594 Other stimulant use, unspecified with stimulant-induced mood disorder 55 55 55 Yes Yes Yes No
F15950 Other stimulant use, unspecified with stimulant-induced psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F15951 Other stimulant use, unspecified with stimulant-induced psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F15959 Other stimulant use, unspecified with stimulant-induced psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F15980 Other stimulant use, unspecified with stimulant-induced anxiety disorder 55 55 55 Yes Yes Yes No
F15981 Other stimulant use, unspecified with stimulant-induced sexual dysfunction 55 55 55 Yes Yes Yes No
F15982 Other stimulant use, unspecified with stimulant-induced sleep disorder 55 55 55 Yes Yes Yes No
F15988 Other stimulant use, unspecified with other stimulant-induced disorder 55 55 55 Yes Yes Yes No
F1599 Other stimulant use, unspecified with unspecified stimulant-induced disorder 55 55 55 Yes Yes Yes No
F1610 Hallucinogen abuse, uncomplicated 56 No No Yes No
F1611 Hallucinogen abuse, in remission 56 No No Yes No
F16120 Hallucinogen abuse with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F16121 Hallucinogen abuse with intoxication with delirium 55 55 55 Yes Yes Yes No
F16122 Hallucinogen abuse with intoxication with perceptual disturbance 55 55 55 Yes Yes Yes No
F16129 Hallucinogen abuse with intoxication, unspecified 55 55 55 Yes Yes Yes No
F1614 Hallucinogen abuse with hallucinogen-induced mood disorder 55 55 55 Yes Yes Yes No
F16150 Hallucinogen abuse with hallucinogen-induced psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F16151 Hallucinogen abuse with hallucinogen-induced psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F16159 Hallucinogen abuse with hallucinogen-induced psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F16180 Hallucinogen abuse with hallucinogen-induced anxiety disorder 55 55 55 Yes Yes Yes No
F16183 Hallucinogen abuse with hallucinogen persisting perception disorder (flashbacks) 55 55 55 Yes Yes Yes No
F16188 Hallucinogen abuse with other hallucinogen-induced disorder 55 55 55 Yes Yes Yes No
F1619 Hallucinogen abuse with unspecified hallucinogen-induced disorder 55 55 55 Yes Yes Yes No
F1620 Hallucinogen dependence, uncomplicated 55 55 55 Yes Yes Yes No
F1621 Hallucinogen dependence, in remission 55 55 55 Yes Yes Yes No
F16220 Hallucinogen dependence with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F16221 Hallucinogen dependence with intoxication with delirium 55 55 55 Yes Yes Yes No
F16229 Hallucinogen dependence with intoxication, unspecified 55 55 55 Yes Yes Yes No
F1624 Hallucinogen dependence with hallucinogen-induced mood disorder 55 55 55 Yes Yes Yes No
F16250 Hallucinogen dependence with hallucinogen-induced psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F16251 Hallucinogen dependence with hallucinogen-induced psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F16259 Hallucinogen dependence with hallucinogen-induced psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F16280 Hallucinogen dependence with hallucinogen-induced anxiety disorder 55 55 55 Yes Yes Yes No
F16283 Hallucinogen dependence with hallucinogen persisting perception disorder (flashbacks) 55 55 55 Yes Yes Yes No
F16288 Hallucinogen dependence with other hallucinogen-induced disorder 55 55 55 Yes Yes Yes No
F1629 Hallucinogen dependence with unspecified hallucinogen-induced disorder 55 55 55 Yes Yes Yes No
F16920 Hallucinogen use, unspecified with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F16921 Hallucinogen use, unspecified with intoxication with delirium 55 55 55 Yes Yes Yes No
F16929 Hallucinogen use, unspecified with intoxication, unspecified 55 55 55 Yes Yes Yes No
F1694 Hallucinogen use, unspecified with hallucinogen-induced mood disorder 55 55 55 Yes Yes Yes No
F16950 Hallucinogen use, unspecified with hallucinogen-induced psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F16951 Hallucinogen use, unspecified with hallucinogen-induced psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F16959 Hallucinogen use, unspecified with hallucinogen-induced psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F16980 Hallucinogen use, unspecified with hallucinogen-induced anxiety disorder 55 55 55 Yes Yes Yes No
F16983 Hallucinogen use, unspecified with hallucinogen persisting perception disorder (flashbacks) 55 55 55 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 66 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

F16988 Hallucinogen use, unspecified with other hallucinogen-induced disorder 55 55 55 Yes Yes Yes No
F1699 Hallucinogen use, unspecified with unspecified hallucinogen-induced disorder 55 55 55 Yes Yes Yes No
F1810 Inhalant abuse, uncomplicated 56 No No Yes No
F1811 Inhalant abuse, in remission 56 No No Yes No
F18120 Inhalant abuse with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F18121 Inhalant abuse with intoxication delirium 55 55 55 Yes Yes Yes No
F18129 Inhalant abuse with intoxication, unspecified 55 55 55 Yes Yes Yes No
F1814 Inhalant abuse with inhalant-induced mood disorder 55 55 55 Yes Yes Yes No
F18150 Inhalant abuse with inhalant-induced psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F18151 Inhalant abuse with inhalant-induced psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F18159 Inhalant abuse with inhalant-induced psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F1817 Inhalant abuse with inhalant-induced dementia 54 54 54 Yes Yes Yes No
F18180 Inhalant abuse with inhalant-induced anxiety disorder 55 55 55 Yes Yes Yes No
F18188 Inhalant abuse with other inhalant-induced disorder 55 55 55 Yes Yes Yes No
F1819 Inhalant abuse with unspecified inhalant-induced disorder 55 55 55 Yes Yes Yes No
F1820 Inhalant dependence, uncomplicated 55 55 55 Yes Yes Yes No
F1821 Inhalant dependence, in remission 55 55 55 Yes Yes Yes No
F18220 Inhalant dependence with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F18221 Inhalant dependence with intoxication delirium 55 55 55 Yes Yes Yes No
F18229 Inhalant dependence with intoxication, unspecified 55 55 55 Yes Yes Yes No
F1824 Inhalant dependence with inhalant-induced mood disorder 55 55 55 Yes Yes Yes No
F18250 Inhalant dependence with inhalant-induced psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F18251 Inhalant dependence with inhalant-induced psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F18259 Inhalant dependence with inhalant-induced psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F1827 Inhalant dependence with inhalant-induced dementia 54 54 54 Yes Yes Yes No
F18280 Inhalant dependence with inhalant-induced anxiety disorder 55 55 55 Yes Yes Yes No
F18288 Inhalant dependence with other inhalant-induced disorder 55 55 55 Yes Yes Yes No
F1829 Inhalant dependence with unspecified inhalant-induced disorder 55 55 55 Yes Yes Yes No
F18920 Inhalant use, unspecified with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F18921 Inhalant use, unspecified with intoxication with delirium 55 55 55 Yes Yes Yes No
F18929 Inhalant use, unspecified with intoxication, unspecified 55 55 55 Yes Yes Yes No
F1894 Inhalant use, unspecified with inhalant-induced mood disorder 55 55 55 Yes Yes Yes No
F18950 Inhalant use, unspecified with inhalant-induced psychotic disorder with delusions 54 54 54 Yes Yes Yes No
F18951 Inhalant use, unspecified with inhalant-induced psychotic disorder with hallucinations 54 54 54 Yes Yes Yes No
F18959 Inhalant use, unspecified with inhalant-induced psychotic disorder, unspecified 54 54 54 Yes Yes Yes No
F1897 Inhalant use, unspecified with inhalant-induced persisting dementia 54 54 54 Yes Yes Yes No
F18980 Inhalant use, unspecified with inhalant-induced anxiety disorder 55 55 55 Yes Yes Yes No
F18988 Inhalant use, unspecified with other inhalant-induced disorder 55 55 55 Yes Yes Yes No
F1899 Inhalant use, unspecified with unspecified inhalant-induced disorder 55 55 55 Yes Yes Yes No
F1910 Other psychoactive substance abuse, uncomplicated 56 No No Yes No
F1911 Other psychoactive substance abuse, in remission 56 No No Yes No
F19120 Other psychoactive substance abuse with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F19121 Other psychoactive substance abuse with intoxication delirium 55 55 55 Yes Yes Yes No
F19122 Other psychoactive substance abuse with intoxication with perceptual disturbances 55 55 55 Yes Yes Yes No
F19129 Other psychoactive substance abuse with intoxication, unspecified 55 55 55 Yes Yes Yes No
F19130 Other psychoactive substance abuse with withdrawal, uncomplicated 55 55 55 Yes Yes Yes No
F19131 Other psychoactive substance abuse with withdrawal delirium 54 54 54 Yes Yes Yes No
F19132 Other psychoactive substance abuse with withdrawal with perceptual disturbance 54 54 54 Yes Yes Yes No
F19139 Other psychoactive substance abuse with withdrawal, unspecified 55 55 55 Yes Yes Yes No
F1914 Other psychoactive substance abuse with psychoactive substance-induced mood disorder 55 55 55 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 67 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

F19150 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with 54 54 54 Yes Yes Yes No
delusions
F19151 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with 54 54 54 Yes Yes Yes No
hallucinations
F19159 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder, 54 54 54 Yes Yes Yes No
unspecified
F1916 Other psychoactive substance abuse with psychoactive substance-induced persisting amnestic 54 54 54 Yes Yes Yes No
disorder
F1917 Other psychoactive substance abuse with psychoactive substance-induced persisting dementia 54 54 54 Yes Yes Yes No
F19180 Other psychoactive substance abuse with psychoactive substance-induced anxiety disorder 55 55 55 Yes Yes Yes No
F19181 Other psychoactive substance abuse with psychoactive substance-induced sexual dysfunction 55 55 55 Yes Yes Yes No
F19182 Other psychoactive substance abuse with psychoactive substance-induced sleep disorder 55 55 55 Yes Yes Yes No
F19188 Other psychoactive substance abuse with other psychoactive substance-induced disorder 55 55 55 Yes Yes Yes No
F1919 Other psychoactive substance abuse with unspecified psychoactive substance-induced disorder 55 55 55 Yes Yes Yes No
F1920 Other psychoactive substance dependence, uncomplicated 55 55 55 Yes Yes Yes No
F1921 Other psychoactive substance dependence, in remission 55 55 55 Yes Yes Yes No
F19220 Other psychoactive substance dependence with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F19221 Other psychoactive substance dependence with intoxication delirium 55 55 55 Yes Yes Yes No
F19222 Other psychoactive substance dependence with intoxication with perceptual disturbance 55 55 55 Yes Yes Yes No
F19229 Other psychoactive substance dependence with intoxication, unspecified 55 55 55 Yes Yes Yes No
F19230 Other psychoactive substance dependence with withdrawal, uncomplicated 55 55 55 Yes Yes Yes No
F19231 Other psychoactive substance dependence with withdrawal delirium 54 54 54 Yes Yes Yes No
F19232 Other psychoactive substance dependence with withdrawal with perceptual disturbance 54 54 54 Yes Yes Yes No
F19239 Other psychoactive substance dependence with withdrawal, unspecified 55 55 55 Yes Yes Yes No
F1924 Other psychoactive substance dependence with psychoactive substance-induced mood disorder 55 55 55 Yes Yes Yes No
F19250 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder 54 54 54 Yes Yes Yes No
with delusions
F19251 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder 54 54 54 Yes Yes Yes No
with hallucinations
F19259 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder, 54 54 54 Yes Yes Yes No
unspecified
F1926 Other psychoactive substance dependence with psychoactive substance-induced persisting amnestic 54 54 54 Yes Yes Yes No
disorder
F1927 Other psychoactive substance dependence with psychoactive substance-induced persisting dementia 54 54 54 Yes Yes Yes No
F19280 Other psychoactive substance dependence with psychoactive substance-induced anxiety disorder 55 55 55 Yes Yes Yes No
F19281 Other psychoactive substance dependence with psychoactive substance-induced sexual dysfunction 55 55 55 Yes Yes Yes No
F19282 Other psychoactive substance dependence with psychoactive substance-induced sleep disorder 55 55 55 Yes Yes Yes No
F19288 Other psychoactive substance dependence with other psychoactive substance-induced disorder 55 55 55 Yes Yes Yes No
F1929 Other psychoactive substance dependence with unspecified psychoactive substance-induced 55 55 55 Yes Yes Yes No
disorder
F19920 Other psychoactive substance use, unspecified with intoxication, uncomplicated 55 55 55 Yes Yes Yes No
F19921 Other psychoactive substance use, unspecified with intoxication with delirium 55 55 55 Yes Yes Yes No
F19922 Other psychoactive substance use, unspecified with intoxication with perceptual disturbance 55 55 55 Yes Yes Yes No
F19929 Other psychoactive substance use, unspecified with intoxication, unspecified 55 55 55 Yes Yes Yes No
F19930 Other psychoactive substance use, unspecified with withdrawal, uncomplicated 55 55 55 Yes Yes Yes No
F19931 Other psychoactive substance use, unspecified with withdrawal delirium 54 54 54 Yes Yes Yes No
F19932 Other psychoactive substance use, unspecified with withdrawal with perceptual disturbance 54 54 54 Yes Yes Yes No
F19939 Other psychoactive substance use, unspecified with withdrawal, unspecified 55 55 55 Yes Yes Yes No
F1994 Other psychoactive substance use, unspecified with psychoactive substance-induced mood disorder 55 55 55 Yes Yes Yes No
F19950 Other psychoactive substance use, unspecified with psychoactive substance-induced psychotic 54 54 54 Yes Yes Yes No
disorder with delusions

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 68 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

F19951 Other psychoactive substance use, unspecified with psychoactive substance-induced psychotic 54 54 54 Yes Yes Yes No
disorder with hallucinations
F19959 Other psychoactive substance use, unspecified with psychoactive substance-induced psychotic 54 54 54 Yes Yes Yes No
disorder, unspecified
F1996 Other psychoactive substance use, unspecified with psychoactive substance-induced persisting 54 54 54 Yes Yes Yes No
amnestic disorder
F1997 Other psychoactive substance use, unspecified with psychoactive substance-induced persisting 54 54 54 Yes Yes Yes No
dementia
F19980 Other psychoactive substance use, unspecified with psychoactive substance-induced anxiety 55 55 55 Yes Yes Yes No
disorder
F19981 Other psychoactive substance use, unspecified with psychoactive substance-induced sexual 55 55 55 Yes Yes Yes No
dysfunction
F19982 Other psychoactive substance use, unspecified with psychoactive substance-induced sleep disorder 55 55 55 Yes Yes Yes No
F19988 Other psychoactive substance use, unspecified with other psychoactive substance-induced disorder 55 55 55 Yes Yes Yes No
F1999 Other psychoactive substance use, unspecified with unspecified psychoactive substance-induced 55 55 55 Yes Yes Yes No
disorder
F200 Paranoid schizophrenia 57 57 57 130 Yes Yes Yes Yes
F201 Disorganized schizophrenia 57 57 57 130 Yes Yes Yes Yes
F202 Catatonic schizophrenia 57 57 57 130 Yes Yes Yes Yes
F203 Undifferentiated schizophrenia 57 57 57 130 Yes Yes Yes Yes
F205 Residual schizophrenia 57 57 57 130 Yes Yes Yes Yes
F2081 Schizophreniform disorder 57 57 57 130 Yes Yes Yes Yes
F2089 Other schizophrenia 57 57 57 130 Yes Yes Yes Yes
F209 Schizophrenia, unspecified 57 57 57 130 Yes Yes Yes Yes
F21 Schizotypal disorder 60 No No Yes No
F22 Delusional disorders 58 58 59 Yes Yes Yes No
F23 Brief psychotic disorder 58 No No Yes No
F24 Shared psychotic disorder 58 58 59 Yes Yes Yes No
F250 Schizoaffective disorder, bipolar type 57 57 57 130 Yes Yes Yes Yes
F251 Schizoaffective disorder, depressive type 57 57 57 130 Yes Yes Yes Yes
F258 Other schizoaffective disorders 57 57 57 130 Yes Yes Yes Yes
F259 Schizoaffective disorder, unspecified 57 57 57 130 Yes Yes Yes Yes
F28 Other psychotic disorder not due to a substance or known physiological condition 58 No No Yes No
F29 Unspecified psychosis not due to a substance or known physiological condition 58 No No Yes No
F3010 Manic episode without psychotic symptoms, unspecified 58 58 59 131 Yes Yes Yes Yes
F3011 Manic episode without psychotic symptoms, mild 58 58 59 131 Yes Yes Yes Yes
F3012 Manic episode without psychotic symptoms, moderate 58 58 59 131 Yes Yes Yes Yes
F3013 Manic episode, severe, without psychotic symptoms 58 58 59 131 Yes Yes Yes Yes
F302 Manic episode, severe with psychotic symptoms 58 58 59 131 Yes Yes Yes Yes
F303 Manic episode in partial remission 58 58 59 131 Yes Yes Yes Yes
F304 Manic episode in full remission 58 58 59 131 Yes Yes Yes Yes
F308 Other manic episodes 58 58 59 131 Yes Yes Yes Yes
F309 Manic episode, unspecified 58 58 59 131 Yes Yes Yes Yes
F310 Bipolar disorder, current episode hypomanic 58 58 59 131 Yes Yes Yes Yes
F3110 Bipolar disorder, current episode manic without psychotic features, unspecified 58 58 59 131 Yes Yes Yes Yes
F3111 Bipolar disorder, current episode manic without psychotic features, mild 58 58 59 131 Yes Yes Yes Yes
F3112 Bipolar disorder, current episode manic without psychotic features, moderate 58 58 59 131 Yes Yes Yes Yes
F3113 Bipolar disorder, current episode manic without psychotic features, severe 58 58 59 131 Yes Yes Yes Yes
F312 Bipolar disorder, current episode manic severe with psychotic features 58 58 59 131 Yes Yes Yes Yes
F3130 Bipolar disorder, current episode depressed, mild or moderate severity, unspecified 58 58 59 131 Yes Yes Yes Yes
F3131 Bipolar disorder, current episode depressed, mild 58 58 59 131 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 69 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

F3132 Bipolar disorder, current episode depressed, moderate 58 58 59 131 Yes Yes Yes Yes
F314 Bipolar disorder, current episode depressed, severe, without psychotic features 58 58 59 131 Yes Yes Yes Yes
F315 Bipolar disorder, current episode depressed, severe, with psychotic features 58 58 59 131 Yes Yes Yes Yes
F3160 Bipolar disorder, current episode mixed, unspecified 58 58 59 131 Yes Yes Yes Yes
F3161 Bipolar disorder, current episode mixed, mild 58 58 59 131 Yes Yes Yes Yes
F3162 Bipolar disorder, current episode mixed, moderate 58 58 59 131 Yes Yes Yes Yes
F3163 Bipolar disorder, current episode mixed, severe, without psychotic features 58 58 59 131 Yes Yes Yes Yes
F3164 Bipolar disorder, current episode mixed, severe, with psychotic features 58 58 59 131 Yes Yes Yes Yes
F3170 Bipolar disorder, currently in remission, most recent episode unspecified 58 58 59 131 Yes Yes Yes Yes
F3171 Bipolar disorder, in partial remission, most recent episode hypomanic 58 58 59 131 Yes Yes Yes Yes
F3172 Bipolar disorder, in full remission, most recent episode hypomanic 58 58 59 131 Yes Yes Yes Yes
F3173 Bipolar disorder, in partial remission, most recent episode manic 58 58 59 131 Yes Yes Yes Yes
F3174 Bipolar disorder, in full remission, most recent episode manic 58 58 59 131 Yes Yes Yes Yes
F3175 Bipolar disorder, in partial remission, most recent episode depressed 58 58 59 131 Yes Yes Yes Yes
F3176 Bipolar disorder, in full remission, most recent episode depressed 58 58 59 131 Yes Yes Yes Yes
F3177 Bipolar disorder, in partial remission, most recent episode mixed 58 58 59 131 Yes Yes Yes Yes
F3178 Bipolar disorder, in full remission, most recent episode mixed 58 58 59 131 Yes Yes Yes Yes
F3181 Bipolar II disorder 58 58 59 131 Yes Yes Yes Yes
F3189 Other bipolar disorder 58 58 59 131 Yes Yes Yes Yes
F319 Bipolar disorder, unspecified 58 58 59 131 Yes Yes Yes Yes
F320 Major depressive disorder, single episode, mild 58 58 59 132 Yes Yes Yes Yes
F321 Major depressive disorder, single episode, moderate 58 58 59 132 Yes Yes Yes Yes
F322 Major depressive disorder, single episode, severe without psychotic features 58 58 59 132 Yes Yes Yes Yes
F323 Major depressive disorder, single episode, severe with psychotic features 58 58 59 132 Yes Yes Yes Yes
F324 Major depressive disorder, single episode, in partial remission 58 58 59 132 Yes Yes Yes Yes
F325 Major depressive disorder, single episode, in full remission 58 58 59 132 Yes Yes Yes Yes
F3281 Premenstrual dysphoric disorder 134 No No No Yes
F3289 Other specified depressive episodes 134 No No No Yes
F329 Major depressive disorder, single episode, unspecified 134 No No No Yes
F330 Major depressive disorder, recurrent, mild 58 58 59 132 Yes Yes Yes Yes
F331 Major depressive disorder, recurrent, moderate 58 58 59 132 Yes Yes Yes Yes
F332 Major depressive disorder, recurrent severe without psychotic features 58 58 59 132 Yes Yes Yes Yes
F333 Major depressive disorder, recurrent, severe with psychotic symptoms 58 58 59 132 Yes Yes Yes Yes
F3340 Major depressive disorder, recurrent, in remission, unspecified 58 58 59 132 Yes Yes Yes Yes
F3341 Major depressive disorder, recurrent, in partial remission 58 58 59 132 Yes Yes Yes Yes
F3342 Major depressive disorder, recurrent, in full remission 58 58 59 132 Yes Yes Yes Yes
F338 Other recurrent depressive disorders 58 58 59 132 Yes Yes Yes Yes
F339 Major depressive disorder, recurrent, unspecified 58 58 59 132 Yes Yes Yes Yes
F340 Cyclothymic disorder 134 No No No Yes
F341 Dysthymic disorder 134 No No No Yes
F3481 Disruptive mood dysregulation disorder 58 58 59 131 Yes Yes Yes Yes
F3489 Other specified persistent mood disorders 58 58 59 131 Yes Yes Yes Yes
F349 Persistent mood [affective] disorder, unspecified 58 58 59 131 Yes Yes Yes Yes
F39 Unspecified mood [affective] disorder 58 58 59 131 Yes Yes Yes Yes
F4000 Agoraphobia, unspecified 135 No No No Yes
F4001 Agoraphobia with panic disorder 135 No No No Yes
F4002 Agoraphobia without panic disorder 135 No No No Yes
F4010 Social phobia, unspecified 135 No No No Yes
F4011 Social phobia, generalized 135 No No No Yes
F40210 Arachnophobia 135 No No No Yes
F40218 Other animal type phobia 135 No No No Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 70 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

F40220 Fear of thunderstorms 135 No No No Yes


F40228 Other natural environment type phobia 135 No No No Yes
F40230 Fear of blood 135 No No No Yes
F40231 Fear of injections and transfusions 135 No No No Yes
F40232 Fear of other medical care 135 No No No Yes
F40233 Fear of injury 135 No No No Yes
F40240 Claustrophobia 135 No No No Yes
F40241 Acrophobia 135 No No No Yes
F40242 Fear of bridges 135 No No No Yes
F40243 Fear of flying 135 No No No Yes
F40248 Other situational type phobia 135 No No No Yes
F40290 Androphobia 135 No No No Yes
F40291 Gynephobia 135 No No No Yes
F40298 Other specified phobia 135 No No No Yes
F408 Other phobic anxiety disorders 135 No No No Yes
F409 Phobic anxiety disorder, unspecified 135 No No No Yes
F410 Panic disorder [episodic paroxysmal anxiety] 135 No No No Yes
F411 Generalized anxiety disorder 135 No No No Yes
F422 Mixed obsessional thoughts and acts 133 No No No Yes
F423 Hoarding disorder 133 No No No Yes
F424 Excoriation (skin-picking) disorder 133 No No No Yes
F428 Other obsessive-compulsive disorder 133 No No No Yes
F429 Obsessive-compulsive disorder, unspecified 133 No No No Yes
F4310 Post-traumatic stress disorder, unspecified 133 No No No Yes
F4311 Post-traumatic stress disorder, acute 133 No No No Yes
F4312 Post-traumatic stress disorder, chronic 133 No No No Yes
F440 Dissociative amnesia 60 133 No No Yes Yes
F441 Dissociative fugue 60 133 No No Yes Yes
F442 Dissociative stupor 135 No No No Yes
F444 Conversion disorder with motor symptom or deficit 135 No No No Yes
F445 Conversion disorder with seizures or convulsions 135 No No No Yes
F446 Conversion disorder with sensory symptom or deficit 135 No No No Yes
F447 Conversion disorder with mixed symptom presentation 135 No No No Yes
F4481 Dissociative identity disorder 60 133 No No Yes Yes
F4489 Other dissociative and conversion disorders 135 No No No Yes
F449 Dissociative and conversion disorder, unspecified 135 No No No Yes
F450 Somatization disorder 135 No No No Yes
F451 Undifferentiated somatoform disorder 135 No No No Yes
F4520 Hypochondriacal disorder, unspecified 135 No No No Yes
F4521 Hypochondriasis 135 No No No Yes
F4522 Body dysmorphic disorder 135 No No No Yes
F4529 Other hypochondriacal disorders 135 No No No Yes
F458 Other somatoform disorders 135 No No No Yes
F459 Somatoform disorder, unspecified 135 No No No Yes
F481 Depersonalization-derealization syndrome 60 133 No No Yes Yes
F5000 Anorexia nervosa, unspecified 133 No No No Yes
F5001 Anorexia nervosa, restricting type 133 No No No Yes
F5002 Anorexia nervosa, binge eating/purging type 133 No No No Yes
F502 Bulimia nervosa 133 No No No Yes
F530 Postpartum depression 134 No No No Yes
F531 Puerperal psychosis 58 No No Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 71 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

F600 Paranoid personality disorder 60 No No Yes No


F601 Schizoid personality disorder 60 No No Yes No
F602 Antisocial personality disorder 60 No No Yes No
F603 Borderline personality disorder 60 133 No No Yes Yes
F604 Histrionic personality disorder 60 No No Yes No
F605 Obsessive-compulsive personality disorder 60 133 No No Yes Yes
F606 Avoidant personality disorder 60 No No Yes No
F607 Dependent personality disorder 60 No No Yes No
F6081 Narcissistic personality disorder 60 No No Yes No
F6089 Other specific personality disorders 60 No No Yes No
F609 Personality disorder, unspecified 60 No No Yes No
F630 Pathological gambling 133 No No No Yes
F631 Pyromania 133 No No No Yes
F632 Kleptomania 133 No No No Yes
F633 Trichotillomania 133 No No No Yes
F6381 Intermittent explosive disorder 133 No No No Yes
F6389 Other impulse disorders 133 No No No Yes
F639 Impulse disorder, unspecified 133 No No No Yes
F6810 Factitious disorder imposed on self, unspecified 135 No No No Yes
F6811 Factitious disorder imposed on self, with predominantly psychological signs and symptoms 135 No No No Yes
F6812 Factitious disorder imposed on self, with predominantly physical signs and symptoms 135 No No No Yes
F6813 Factitious disorder imposed on self, with combined psychological and physical signs and symptoms 135 No No No Yes
F68A Factitious disorder imposed on another 135 No No No Yes
F70 Mild intellectual disabilities 148 No No No Yes
F71 Moderate intellectual disabilities 147 No No No Yes
F72 Severe intellectual disabilities 146 No No No Yes
F73 Profound intellectual disabilities 146 No No No Yes
F78 Other intellectual disabilities 148 No No No Yes
F79 Unspecified intellectual disabilities 148 No No No Yes
F840 Autistic disorder 145 No No No Yes
F842 Rett's syndrome 145 No No No Yes
F843 Other childhood disintegrative disorder 145 No No No Yes
F845 Asperger's syndrome 145 No No No Yes
F848 Other pervasive developmental disorders 145 No No No Yes
F849 Pervasive developmental disorder, unspecified 145 No No No Yes
F900 Attention-deficit hyperactivity disorder, predominantly inattentive type 133 No No No Yes
F901 Attention-deficit hyperactivity disorder, predominantly hyperactive type 133 No No No Yes
F902 Attention-deficit hyperactivity disorder, combined type 133 No No No Yes
F908 Attention-deficit hyperactivity disorder, other type 133 No No No Yes
F909 Attention-deficit hyperactivity disorder, unspecified type 133 No No No Yes
F910 Conduct disorder confined to family context 133 No No No Yes
F911 Conduct disorder, childhood-onset type 133 No No No Yes
F912 Conduct disorder, adolescent-onset type 133 No No No Yes
F913 Oppositional defiant disorder 133 No No No Yes
F918 Other conduct disorders 133 No No No Yes
F919 Conduct disorder, unspecified 133 No No No Yes
F952 Tourette's disorder 133 No No No Yes
F984 Stereotyped movement disorders 133 No No No Yes
G041 Tropical spastic paraplegia 72 72 72 157 Yes Yes Yes Yes
G0489 Other myelitis 72 72 72 157 Yes Yes Yes Yes
G0491 Myelitis, unspecified 72 72 72 157 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 72 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

G054 Myelitis in diseases classified elsewhere 72 72 72 157 Yes Yes Yes Yes
G10 Huntington's disease 78 78 78 161 Yes Yes Yes Yes
G110 Congenital nonprogressive ataxia 72 72 72 Yes Yes Yes No
G111 Early-onset cerebellar ataxia 72 72 72 Yes Yes Yes No
G1110 Early-onset cerebellar ataxia, unspecified 72 72 72 Yes Yes Yes No
G1111 Friedreich ataxia 72 72 72 Yes Yes Yes No
G1119 Other early-onset cerebellar ataxia 72 72 72 Yes Yes Yes No
G112 Late-onset cerebellar ataxia 72 72 72 Yes Yes Yes No
G113 Cerebellar ataxia with defective DNA repair 72 72 72 Yes Yes Yes No
G114 Hereditary spastic paraplegia 72 72 72 Yes Yes Yes No
G118 Other hereditary ataxias 72 72 72 Yes Yes Yes No
G119 Hereditary ataxia, unspecified 72 72 72 Yes Yes Yes No
G120 Infantile spinal muscular atrophy, type I [Werdnig-Hoffman] 72 72 72 157 Yes Yes Yes Yes
G121 Other inherited spinal muscular atrophy 72 72 72 157 Yes Yes Yes Yes
G1220 Motor neuron disease, unspecified 73 73 73 156 Yes Yes Yes Yes
G1221 Amyotrophic lateral sclerosis 73 73 73 156 Yes Yes Yes Yes
G1222 Progressive bulbar palsy 73 73 73 156 Yes Yes Yes Yes
G1223 Primary lateral sclerosis 73 73 73 156 Yes Yes Yes Yes
G1224 Familial motor neuron disease 73 73 73 156 Yes Yes Yes Yes
G1225 Progressive spinal muscle atrophy 73 73 73 156 Yes Yes Yes Yes
G1229 Other motor neuron disease 73 73 73 156 Yes Yes Yes Yes
G128 Other spinal muscular atrophies and related syndromes 72 72 72 157 Yes Yes Yes Yes
G129 Spinal muscular atrophy, unspecified 72 72 72 157 Yes Yes Yes Yes
G130 Paraneoplastic neuromyopathy and neuropathy 75 75 75 159 Yes Yes Yes Yes
G131 Other systemic atrophy primarily affecting central nervous system in neoplastic disease 75 75 75 159 Yes Yes Yes Yes
G132 Systemic atrophy primarily affecting the central nervous system in myxedema 52 52 112 Yes No Yes Yes
G138 Systemic atrophy primarily affecting central nervous system in other diseases classified elsewhere 52 52 112 Yes No Yes Yes
G20 Parkinson's disease 78 78 78 161 Yes Yes Yes Yes
G2111 Neuroleptic induced parkinsonism 78 78 78 161 Yes Yes Yes Yes
G2119 Other drug induced secondary parkinsonism 78 78 78 161 Yes Yes Yes Yes
G212 Secondary parkinsonism due to other external agents 78 78 78 161 Yes Yes Yes Yes
G213 Postencephalitic parkinsonism 78 78 78 161 Yes Yes Yes Yes
G214 Vascular parkinsonism 78 78 78 161 Yes Yes Yes Yes
G218 Other secondary parkinsonism 78 78 78 161 Yes Yes Yes Yes
G219 Secondary parkinsonism, unspecified 78 78 78 161 Yes Yes Yes Yes
G230 Hallervorden-Spatz disease 78 78 78 Yes Yes Yes No
G231 Progressive supranuclear ophthalmoplegia [Steele-Richardson-Olszewski] 78 78 78 Yes Yes Yes No
G232 Striatonigral degeneration 78 78 78 Yes Yes Yes No
G238 Other specified degenerative diseases of basal ganglia 78 78 78 Yes Yes Yes No
G239 Degenerative disease of basal ganglia, unspecified 78 78 78 Yes Yes Yes No
G300 Alzheimer's disease with early onset 52 52 111 Yes No Yes Yes
G301 Alzheimer's disease with late onset 52 52 111 Yes No Yes Yes
G308 Other Alzheimer's disease 52 52 111 Yes No Yes Yes
G309 Alzheimer's disease, unspecified 52 52 111 Yes No Yes Yes
G3101 Pick's disease 52 52 112 Yes No Yes Yes
G3109 Other frontotemporal dementia 52 52 112 Yes No Yes Yes
G311 Senile degeneration of brain, not elsewhere classified 52 52 112 Yes No Yes Yes
G312 Degeneration of nervous system due to alcohol 52 52 112 Yes No Yes Yes
G3181 Alpers disease 52 52 112 Yes No Yes Yes
G3182 Leigh's disease 52 52 112 Yes No Yes Yes
G3183 Dementia with Lewy bodies 52 52 112 Yes No Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 73 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

G3185 Corticobasal degeneration 52 52 112 Yes No Yes Yes


G3189 Other specified degenerative diseases of nervous system 52 52 112 Yes No Yes Yes
G319 Degenerative disease of nervous system, unspecified 52 52 112 Yes No Yes Yes
G320 Subacute combined degeneration of spinal cord in diseases classified elsewhere 72 72 72 157 Yes Yes Yes Yes
G3281 Cerebellar ataxia in diseases classified elsewhere 72 72 72 Yes Yes Yes No
G35 Multiple sclerosis 77 77 77 160 Yes Yes Yes Yes
G360 Neuromyelitis optica [Devic] 77 77 77 160 Yes Yes Yes Yes
G361 Acute and subacute hemorrhagic leukoencephalitis [Hurst] 77 77 77 Yes Yes Yes No
G368 Other specified acute disseminated demyelination 77 77 77 Yes Yes Yes No
G369 Acute disseminated demyelination, unspecified 77 77 77 Yes Yes Yes No
G370 Diffuse sclerosis of central nervous system 77 77 77 160 Yes Yes Yes Yes
G371 Central demyelination of corpus callosum 77 77 77 Yes Yes Yes No
G372 Central pontine myelinolysis 77 77 77 Yes Yes Yes No
G373 Acute transverse myelitis in demyelinating disease of central nervous system 72 72 72 157 Yes Yes Yes Yes
G374 Subacute necrotizing myelitis of central nervous system 72 72 72 157 Yes Yes Yes Yes
G375 Concentric sclerosis [Balo] of central nervous system 77 77 77 160 Yes Yes Yes Yes
G378 Other specified demyelinating diseases of central nervous system 77 77 77 Yes Yes Yes No
G379 Demyelinating disease of central nervous system, unspecified 77 77 77 Yes Yes Yes No
G40001 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of 79 79 79 164 Yes Yes Yes Yes
localized onset, not intractable, with status epilepticus
G40009 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of 79 79 79 164 Yes Yes Yes Yes
localized onset, not intractable, without status epilepticus
G40011 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of 79 79 79 163 Yes Yes Yes Yes
localized onset, intractable, with status epilepticus
G40019 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of 79 79 79 163 Yes Yes Yes Yes
localized onset, intractable, without status epilepticus
G40101 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple 79 79 79 164 Yes Yes Yes Yes
partial seizures, not intractable, with status epilepticus
G40109 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple 79 79 79 164 Yes Yes Yes Yes
partial seizures, not intractable, without status epilepticus
G40111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple 79 79 79 163 Yes Yes Yes Yes
partial seizures, intractable, with status epilepticus
G40119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple 79 79 79 163 Yes Yes Yes Yes
partial seizures, intractable, without status epilepticus
G40201 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex 79 79 79 164 Yes Yes Yes Yes
partial seizures, not intractable, with status epilepticus
G40209 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex 79 79 79 164 Yes Yes Yes Yes
partial seizures, not intractable, without status epilepticus
G40211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex 79 79 79 163 Yes Yes Yes Yes
partial seizures, intractable, with status epilepticus
G40219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex 79 79 79 163 Yes Yes Yes Yes
partial seizures, intractable, without status epilepticus
G40301 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus 79 79 79 164 Yes Yes Yes Yes
G40309 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus 79 79 79 164 Yes Yes Yes Yes
G40311 Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus 79 79 79 163 Yes Yes Yes Yes
G40319 Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus 79 79 79 163 Yes Yes Yes Yes
G40401 Other generalized epilepsy and epileptic syndromes, not intractable, with status epilepticus 79 79 79 164 Yes Yes Yes Yes
G40409 Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus 79 79 79 164 Yes Yes Yes Yes
G40411 Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus 79 79 79 163 Yes Yes Yes Yes
G40419 Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus 79 79 79 163 Yes Yes Yes Yes
G4042 Cyclin-Dependent Kinase-Like 5 Deficiency Disorder 79 79 79 163 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 74 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

G40501 Epileptic seizures related to external causes, not intractable, with status epilepticus 79 79 79 164 Yes Yes Yes Yes
G40509 Epileptic seizures related to external causes, not intractable, without status epilepticus 79 79 79 164 Yes Yes Yes Yes
G40801 Other epilepsy, not intractable, with status epilepticus 79 79 79 164 Yes Yes Yes Yes
G40802 Other epilepsy, not intractable, without status epilepticus 79 79 79 164 Yes Yes Yes Yes
G40803 Other epilepsy, intractable, with status epilepticus 79 79 79 163 Yes Yes Yes Yes
G40804 Other epilepsy, intractable, without status epilepticus 79 79 79 163 Yes Yes Yes Yes
G40811 Lennox-Gastaut syndrome, not intractable, with status epilepticus 79 79 79 164 Yes Yes Yes Yes
G40812 Lennox-Gastaut syndrome, not intractable, without status epilepticus 79 79 79 164 Yes Yes Yes Yes
G40813 Lennox-Gastaut syndrome, intractable, with status epilepticus 79 79 79 163 Yes Yes Yes Yes
G40814 Lennox-Gastaut syndrome, intractable, without status epilepticus 79 79 79 163 Yes Yes Yes Yes
G40821 Epileptic spasms, not intractable, with status epilepticus 79 79 79 164 Yes Yes Yes Yes
G40822 Epileptic spasms, not intractable, without status epilepticus 79 79 79 164 Yes Yes Yes Yes
G40823 Epileptic spasms, intractable, with status epilepticus 79 79 79 163 Yes Yes Yes Yes
G40824 Epileptic spasms, intractable, without status epilepticus 79 79 79 163 Yes Yes Yes Yes
G40833 Dravet syndrome, intractable, with status epilepticus 79 79 79 163 Yes Yes Yes Yes
G40834 Dravet syndrome, intractable, without status epilepticus 79 79 79 163 Yes Yes Yes Yes
G4089 Other seizures 79 79 79 164 Yes Yes Yes Yes
G40901 Epilepsy, unspecified, not intractable, with status epilepticus 79 79 79 164 Yes Yes Yes Yes
G40909 Epilepsy, unspecified, not intractable, without status epilepticus 79 79 79 164 Yes Yes Yes Yes
G40911 Epilepsy, unspecified, intractable, with status epilepticus 79 79 79 163 Yes Yes Yes Yes
G40919 Epilepsy, unspecified, intractable, without status epilepticus 79 79 79 163 Yes Yes Yes Yes
G40A01 Absence epileptic syndrome, not intractable, with status epilepticus 79 79 79 164 Yes Yes Yes Yes
G40A09 Absence epileptic syndrome, not intractable, without status epilepticus 79 79 79 164 Yes Yes Yes Yes
G40A11 Absence epileptic syndrome, intractable, with status epilepticus 79 79 79 163 Yes Yes Yes Yes
G40A19 Absence epileptic syndrome, intractable, without status epilepticus 79 79 79 163 Yes Yes Yes Yes
G40B01 Juvenile myoclonic epilepsy, not intractable, with status epilepticus 79 79 79 164 Yes Yes Yes Yes
G40B09 Juvenile myoclonic epilepsy, not intractable, without status epilepticus 79 79 79 164 Yes Yes Yes Yes
G40B11 Juvenile myoclonic epilepsy, intractable, with status epilepticus 79 79 79 163 Yes Yes Yes Yes
G40B19 Juvenile myoclonic epilepsy, intractable, without status epilepticus 79 79 79 163 Yes Yes Yes Yes
G43001 Migraine without aura, not intractable, with status migrainosus 166 No No No Yes
G43009 Migraine without aura, not intractable, without status migrainosus 166 No No No Yes
G43011 Migraine without aura, intractable, with status migrainosus 166 No No No Yes
G43019 Migraine without aura, intractable, without status migrainosus 166 No No No Yes
G43101 Migraine with aura, not intractable, with status migrainosus 166 No No No Yes
G43109 Migraine with aura, not intractable, without status migrainosus 166 No No No Yes
G43111 Migraine with aura, intractable, with status migrainosus 166 No No No Yes
G43119 Migraine with aura, intractable, without status migrainosus 166 No No No Yes
G43401 Hemiplegic migraine, not intractable, with status migrainosus 166 No No No Yes
G43409 Hemiplegic migraine, not intractable, without status migrainosus 166 No No No Yes
G43411 Hemiplegic migraine, intractable, with status migrainosus 166 No No No Yes
G43419 Hemiplegic migraine, intractable, without status migrainosus 166 No No No Yes
G43501 Persistent migraine aura without cerebral infarction, not intractable, with status migrainosus 166 No No No Yes
G43509 Persistent migraine aura without cerebral infarction, not intractable, without status migrainosus 166 No No No Yes
G43511 Persistent migraine aura without cerebral infarction, intractable, with status migrainosus 166 No No No Yes
G43519 Persistent migraine aura without cerebral infarction, intractable, without status migrainosus 166 No No No Yes
G43601 Persistent migraine aura with cerebral infarction, not intractable, with status migrainosus 166 No No No Yes
G43609 Persistent migraine aura with cerebral infarction, not intractable, without status migrainosus 166 No No No Yes
G43611 Persistent migraine aura with cerebral infarction, intractable, with status migrainosus 166 No No No Yes
G43619 Persistent migraine aura with cerebral infarction, intractable, without status migrainosus 166 No No No Yes
G43701 Chronic migraine without aura, not intractable, with status migrainosus 166 No No No Yes
G43709 Chronic migraine without aura, not intractable, without status migrainosus 166 No No No Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 75 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

G43711 Chronic migraine without aura, intractable, with status migrainosus 166 No No No Yes
G43719 Chronic migraine without aura, intractable, without status migrainosus 166 No No No Yes
G43801 Other migraine, not intractable, with status migrainosus 166 No No No Yes
G43809 Other migraine, not intractable, without status migrainosus 166 No No No Yes
G43811 Other migraine, intractable, with status migrainosus 166 No No No Yes
G43819 Other migraine, intractable, without status migrainosus 166 No No No Yes
G43821 Menstrual migraine, not intractable, with status migrainosus 166 No No No Yes
G43829 Menstrual migraine, not intractable, without status migrainosus 166 No No No Yes
G43831 Menstrual migraine, intractable, with status migrainosus 166 No No No Yes
G43839 Menstrual migraine, intractable, without status migrainosus 166 No No No Yes
G43901 Migraine, unspecified, not intractable, with status migrainosus 166 No No No Yes
G43909 Migraine, unspecified, not intractable, without status migrainosus 166 No No No Yes
G43911 Migraine, unspecified, intractable, with status migrainosus 166 No No No Yes
G43919 Migraine, unspecified, intractable, without status migrainosus 166 No No No Yes
G43A0 Cyclical vomiting, in migraine, not intractable 166 No No No Yes
G43A1 Cyclical vomiting, in migraine, intractable 166 No No No Yes
G43B0 Ophthalmoplegic migraine, not intractable 166 No No No Yes
G43B1 Ophthalmoplegic migraine, intractable 166 No No No Yes
G43C0 Periodic headache syndromes in child or adult, not intractable 166 No No No Yes
G43C1 Periodic headache syndromes in child or adult, intractable 166 No No No Yes
G43D0 Abdominal migraine, not intractable 166 No No No Yes
G43D1 Abdominal migraine, intractable 166 No No No Yes
G450 Vertebro-basilar artery syndrome 206 No No No Yes
G451 Carotid artery syndrome (hemispheric) 206 No No No Yes
G452 Multiple and bilateral precerebral artery syndromes 206 No No No Yes
G458 Other transient cerebral ischemic attacks and related syndromes 206 No No No Yes
G459 Transient cerebral ischemic attack, unspecified 206 No No No Yes
G460 Middle cerebral artery syndrome 206 No No No Yes
G461 Anterior cerebral artery syndrome 206 No No No Yes
G462 Posterior cerebral artery syndrome 206 No No No Yes
G463 Brain stem stroke syndrome 206 No No No Yes
G464 Cerebellar stroke syndrome 206 No No No Yes
G465 Pure motor lacunar syndrome 206 No No No Yes
G466 Pure sensory lacunar syndrome 206 No No No Yes
G467 Other lacunar syndromes 206 No No No Yes
G468 Other vascular syndromes of brain in cerebrovascular diseases 206 No No No Yes
G47411 Narcolepsy with cataplexy 355 No No No Yes
G47419 Narcolepsy without cataplexy 355 No No No Yes
G47421 Narcolepsy in conditions classified elsewhere with cataplexy 355 No No No Yes
G47429 Narcolepsy in conditions classified elsewhere without cataplexy 355 No No No Yes
G500 Trigeminal neuralgia 168 No No No Yes
G501 Atypical facial pain 168 No No No Yes
G508 Other disorders of trigeminal nerve 168 No No No Yes
G509 Disorder of trigeminal nerve, unspecified 168 No No No Yes
G546 Phantom limb syndrome with pain 189 189 189 Yes Yes Yes No
G547 Phantom limb syndrome without pain 189 189 189 Yes Yes Yes No
G600 Hereditary motor and sensory neuropathy 75 Yes No No No
G601 Refsum's disease 75 Yes No No No
G602 Neuropathy in association with hereditary ataxia 75 Yes No No No
G603 Idiopathic progressive neuropathy 75 Yes No No No
G608 Other hereditary and idiopathic neuropathies 75 Yes No No No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 76 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

G609 Hereditary and idiopathic neuropathy, unspecified 75 Yes No No No


G610 Guillain-Barre syndrome 75 75 75 159 Yes Yes Yes Yes
G611 Serum neuropathy 75 75 75 159 Yes Yes Yes Yes
G6181 Chronic inflammatory demyelinating polyneuritis 75 75 75 159 Yes Yes Yes Yes
G6182 Multifocal motor neuropathy 75 75 75 159 Yes Yes Yes Yes
G6189 Other inflammatory polyneuropathies 75 75 75 159 Yes Yes Yes Yes
G619 Inflammatory polyneuropathy, unspecified 75 75 75 159 Yes Yes Yes Yes
G620 Drug-induced polyneuropathy 75 75 75 159 Yes Yes Yes Yes
G621 Alcoholic polyneuropathy 75 75 75 159 Yes Yes Yes Yes
G622 Polyneuropathy due to other toxic agents 75 75 75 159 Yes Yes Yes Yes
G6281 Critical illness polyneuropathy 75 75 75 159 Yes Yes Yes Yes
G6282 Radiation-induced polyneuropathy 75 75 75 159 Yes Yes Yes Yes
G6289 Other specified polyneuropathies 75 Yes No No No
G629 Polyneuropathy, unspecified 75 Yes No No No
G63 Polyneuropathy in diseases classified elsewhere 75 75 75 159 Yes Yes Yes Yes
G64 Other disorders of peripheral nervous system 75 Yes No No No
G650 Sequelae of Guillain-Barre syndrome 75 75 75 159 Yes Yes Yes Yes
G651 Sequelae of other inflammatory polyneuropathy 75 75 75 159 Yes Yes Yes Yes
G652 Sequelae of toxic polyneuropathy 75 75 75 159 Yes Yes Yes Yes
G7000 Myasthenia gravis without (acute) exacerbation 75 75 75 156 Yes Yes Yes Yes
G7001 Myasthenia gravis with (acute) exacerbation 75 75 75 156 Yes Yes Yes Yes
G701 Toxic myoneural disorders 75 75 75 156 Yes Yes Yes Yes
G702 Congenital and developmental myasthenia 75 75 75 156 Yes Yes Yes Yes
G7080 Lambert-Eaton syndrome, unspecified 75 75 75 156 Yes Yes Yes Yes
G7081 Lambert-Eaton syndrome in disease classified elsewhere 75 75 75 156 Yes Yes Yes Yes
G7089 Other specified myoneural disorders 75 75 75 156 Yes Yes Yes Yes
G709 Myoneural disorder, unspecified 75 75 75 156 Yes Yes Yes Yes
G7100 Muscular dystrophy, unspecified 76 76 76 Yes Yes Yes No
G7101 Duchenne or Becker muscular dystrophy 76 76 76 Yes Yes Yes No
G7102 Facioscapulohumeral muscular dystrophy 76 76 76 Yes Yes Yes No
G7109 Other specified muscular dystrophies 76 76 76 Yes Yes Yes No
G7111 Myotonic muscular dystrophy 76 76 76 Yes Yes Yes No
G7112 Myotonia congenita 75 Yes No No No
G7113 Myotonic chondrodystrophy 75 Yes No No No
G7114 Drug induced myotonia 75 Yes No No No
G7119 Other specified myotonic disorders 75 Yes No No No
G712 Congenital myopathies 76 76 76 Yes Yes Yes No
G7120 Congenital myopathy, unspecifed 76 76 76 Yes Yes Yes No
G7121 Nemaline myopathy 76 76 76 Yes Yes Yes No
G71220 X-linked myotubular myopathy 76 76 76 Yes Yes Yes No
G71228 Other centronuclear myopathy 76 76 76 Yes Yes Yes No
G7129 Other congenital myopathy 76 76 76 Yes Yes Yes No
G713 Mitochondrial myopathy, not elsewhere classified 75 Yes No No No
G718 Other primary disorders of muscles 75 Yes No No No
G719 Primary disorder of muscle, unspecified 75 Yes No No No
G720 Drug-induced myopathy 75 Yes No No No
G721 Alcoholic myopathy 75 Yes No No No
G722 Myopathy due to other toxic agents 75 Yes No No No
G723 Periodic paralysis 75 Yes No No No
G7241 Inclusion body myositis [IBM] 75 Yes No No No
G7249 Other inflammatory and immune myopathies, not elsewhere classified 75 Yes No No No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 77 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

G7281 Critical illness myopathy 75 Yes No No No


G7289 Other specified myopathies 75 Yes No No No
G729 Myopathy, unspecified 75 Yes No No No
G731 Lambert-Eaton syndrome in neoplastic disease 75 75 75 156 Yes Yes Yes Yes
G733 Myasthenic syndromes in other diseases classified elsewhere 75 75 75 156 Yes Yes Yes Yes
G737 Myopathy in diseases classified elsewhere 75 Yes No No No
G800 Spastic quadriplegic cerebral palsy 74 74 74 Yes Yes Yes No
G801 Spastic diplegic cerebral palsy 74 74 74 Yes Yes Yes No
G802 Spastic hemiplegic cerebral palsy 74 74 74 Yes Yes Yes No
G803 Athetoid cerebral palsy 74 74 74 Yes Yes Yes No
G804 Ataxic cerebral palsy 74 74 74 Yes Yes Yes No
G808 Other cerebral palsy 74 74 74 Yes Yes Yes No
G809 Cerebral palsy, unspecified 74 74 74 Yes Yes Yes No
G8100 Flaccid hemiplegia affecting unspecified side 103 103 103 Yes Yes Yes No
G8101 Flaccid hemiplegia affecting right dominant side 103 103 103 Yes Yes Yes No
G8102 Flaccid hemiplegia affecting left dominant side 103 103 103 Yes Yes Yes No
G8103 Flaccid hemiplegia affecting right nondominant side 103 103 103 Yes Yes Yes No
G8104 Flaccid hemiplegia affecting left nondominant side 103 103 103 Yes Yes Yes No
G8110 Spastic hemiplegia affecting unspecified side 103 103 103 207 Yes Yes Yes Yes
G8111 Spastic hemiplegia affecting right dominant side 103 103 103 207 Yes Yes Yes Yes
G8112 Spastic hemiplegia affecting left dominant side 103 103 103 207 Yes Yes Yes Yes
G8113 Spastic hemiplegia affecting right nondominant side 103 103 103 207 Yes Yes Yes Yes
G8114 Spastic hemiplegia affecting left nondominant side 103 103 103 207 Yes Yes Yes Yes
G8190 Hemiplegia, unspecified affecting unspecified side 103 103 103 Yes Yes Yes No
G8191 Hemiplegia, unspecified affecting right dominant side 103 103 103 Yes Yes Yes No
G8192 Hemiplegia, unspecified affecting left dominant side 103 103 103 Yes Yes Yes No
G8193 Hemiplegia, unspecified affecting right nondominant side 103 103 103 Yes Yes Yes No
G8194 Hemiplegia, unspecified affecting left nondominant side 103 103 103 Yes Yes Yes No
G8220 Paraplegia, unspecified 71 71 71 Yes Yes Yes No
G8221 Paraplegia, complete 71 71 71 Yes Yes Yes No
G8222 Paraplegia, incomplete 71 71 71 Yes Yes Yes No
G8250 Quadriplegia, unspecified 70 70 70 Yes Yes Yes No
G8251 Quadriplegia, C1-C4 complete 70 70 70 Yes Yes Yes No
G8252 Quadriplegia, C1-C4 incomplete 70 70 70 Yes Yes Yes No
G8253 Quadriplegia, C5-C7 complete 70 70 70 Yes Yes Yes No
G8254 Quadriplegia, C5-C7 incomplete 70 70 70 Yes Yes Yes No
G830 Diplegia of upper limbs 104 104 104 Yes Yes Yes No
G8310 Monoplegia of lower limb affecting unspecified side 104 104 104 Yes Yes Yes No
G8311 Monoplegia of lower limb affecting right dominant side 104 104 104 Yes Yes Yes No
G8312 Monoplegia of lower limb affecting left dominant side 104 104 104 Yes Yes Yes No
G8313 Monoplegia of lower limb affecting right nondominant side 104 104 104 Yes Yes Yes No
G8314 Monoplegia of lower limb affecting left nondominant side 104 104 104 Yes Yes Yes No
G8320 Monoplegia of upper limb affecting unspecified side 104 104 104 Yes Yes Yes No
G8321 Monoplegia of upper limb affecting right dominant side 104 104 104 Yes Yes Yes No
G8322 Monoplegia of upper limb affecting left dominant side 104 104 104 Yes Yes Yes No
G8323 Monoplegia of upper limb affecting right nondominant side 104 104 104 Yes Yes Yes No
G8324 Monoplegia of upper limb affecting left nondominant side 104 104 104 Yes Yes Yes No
G8330 Monoplegia, unspecified affecting unspecified side 104 104 104 Yes Yes Yes No
G8331 Monoplegia, unspecified affecting right dominant side 104 104 104 Yes Yes Yes No
G8332 Monoplegia, unspecified affecting left dominant side 104 104 104 Yes Yes Yes No
G8333 Monoplegia, unspecified affecting right nondominant side 104 104 104 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 78 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

G8334 Monoplegia, unspecified affecting left nondominant side 104 104 104 Yes Yes Yes No
G834 Cauda equina syndrome 72 72 72 157 Yes Yes Yes Yes
G835 Locked-in state 104 104 104 Yes Yes Yes No
G8381 Brown-Sequard syndrome 104 104 104 Yes Yes Yes No
G8382 Anterior cord syndrome 104 104 104 Yes Yes Yes No
G8383 Posterior cord syndrome 104 104 104 Yes Yes Yes No
G8384 Todd's paralysis (postepileptic) 104 104 104 Yes Yes Yes No
G8389 Other specified paralytic syndromes 104 104 104 Yes Yes Yes No
G839 Paralytic syndrome, unspecified 104 104 104 Yes Yes Yes No
G9001 Carotid sinus syncope 75 Yes No No No
G9009 Other idiopathic peripheral autonomic neuropathy 75 Yes No No No
G901 Familial dysautonomia [Riley-Day] 72 72 72 157 Yes Yes Yes Yes
G902 Horner's syndrome 75 Yes No No No
G903 Multi-system degeneration of the autonomic nervous system 78 78 78 Yes Yes Yes No
G904 Autonomic dysreflexia 75 Yes No No No
G9050 Complex regional pain syndrome I, unspecified 75 Yes No No No
G90511 Complex regional pain syndrome I of right upper limb 75 Yes No No No
G90512 Complex regional pain syndrome I of left upper limb 75 Yes No No No
G90513 Complex regional pain syndrome I of upper limb, bilateral 75 Yes No No No
G90519 Complex regional pain syndrome I of unspecified upper limb 75 Yes No No No
G90521 Complex regional pain syndrome I of right lower limb 75 Yes No No No
G90522 Complex regional pain syndrome I of left lower limb 75 Yes No No No
G90523 Complex regional pain syndrome I of lower limb, bilateral 75 Yes No No No
G90529 Complex regional pain syndrome I of unspecified lower limb 75 Yes No No No
G9059 Complex regional pain syndrome I of other specified site 75 Yes No No No
G908 Other disorders of autonomic nervous system 75 Yes No No No
G909 Disorder of the autonomic nervous system, unspecified 75 Yes No No No
G910 Communicating hydrocephalus 51 51 Yes No Yes No
G911 Obstructive hydrocephalus 51 51 Yes No Yes No
G912 (Idiopathic) normal pressure hydrocephalus 51 51 Yes No Yes No
G913 Post-traumatic hydrocephalus, unspecified 51 51 Yes No Yes No
G914 Hydrocephalus in diseases classified elsewhere 51 51 Yes No Yes No
G918 Other hydrocephalus 51 51 Yes No Yes No
G919 Hydrocephalus, unspecified 51 51 Yes No Yes No
G931 Anoxic brain damage, not elsewhere classified 80 80 80 Yes Yes Yes No
G935 Compression of brain 80 80 80 Yes Yes Yes No
G936 Cerebral edema 80 80 80 Yes Yes Yes No
G937 Reye's syndrome 52 52 112 Yes No Yes Yes
G950 Syringomyelia and syringobulbia 72 72 72 157 Yes Yes Yes Yes
G9511 Acute infarction of spinal cord (embolic) (nonembolic) 72 72 72 157 Yes Yes Yes Yes
G9519 Other vascular myelopathies 72 72 72 157 Yes Yes Yes Yes
G9520 Unspecified cord compression 72 72 72 157 Yes Yes Yes Yes
G9529 Other cord compression 72 72 72 157 Yes Yes Yes Yes
G9581 Conus medullaris syndrome 72 72 72 157 Yes Yes Yes Yes
G9589 Other specified diseases of spinal cord 72 72 72 157 Yes Yes Yes Yes
G959 Disease of spinal cord, unspecified 72 72 72 157 Yes Yes Yes Yes
G990 Autonomic neuropathy in diseases classified elsewhere 75 Yes No No No
G992 Myelopathy in diseases classified elsewhere 72 72 72 157 Yes Yes Yes Yes
H353210 Exudative age-related macular degeneration, right eye, stage unspecified 124 124 124 Yes Yes Yes No
H353211 Exudative age-related macular degeneration, right eye, with active choroidal neovascularization 124 124 124 Yes Yes Yes No
H353212 Exudative age-related macular degeneration, right eye, with inactive choroidal neovascularization 124 124 124 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 79 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

H353213 Exudative age-related macular degeneration, right eye, with inactive scar 124 124 124 Yes Yes Yes No
H353220 Exudative age-related macular degeneration, left eye, stage unspecified 124 124 124 Yes Yes Yes No
H353221 Exudative age-related macular degeneration, left eye, with active choroidal neovascularization 124 124 124 Yes Yes Yes No
H353222 Exudative age-related macular degeneration, left eye, with inactive choroidal neovascularization 124 124 124 Yes Yes Yes No
H353223 Exudative age-related macular degeneration, left eye, with inactive scar 124 124 124 Yes Yes Yes No
H353230 Exudative age-related macular degeneration, bilateral, stage unspecified 124 124 124 Yes Yes Yes No
H353231 Exudative age-related macular degeneration, bilateral, with active choroidal neovascularization 124 124 124 Yes Yes Yes No
H353232 Exudative age-related macular degeneration, bilateral, with inactive choroidal neovascularization 124 124 124 Yes Yes Yes No
H353233 Exudative age-related macular degeneration, bilateral, with inactive scar 124 124 124 Yes Yes Yes No
H353290 Exudative age-related macular degeneration, unspecified eye, stage unspecified 124 124 124 Yes Yes Yes No
H353291 Exudative age-related macular degeneration, unspecified eye, with active choroidal 124 124 124 Yes Yes Yes No
neovascularization
H353292 Exudative age-related macular degeneration, unspecified eye, with inactive choroidal 124 124 124 Yes Yes Yes No
neovascularization
H353293 Exudative age-related macular degeneration, unspecified eye, with inactive scar 124 124 124 Yes Yes Yes No
H4010X0 Unspecified open-angle glaucoma, stage unspecified 243 No No No Yes
H4010X1 Unspecified open-angle glaucoma, mild stage 243 No No No Yes
H4010X2 Unspecified open-angle glaucoma, moderate stage 243 No No No Yes
H4010X3 Unspecified open-angle glaucoma, severe stage 243 No No No Yes
H4010X4 Unspecified open-angle glaucoma, indeterminate stage 243 No No No Yes
H401110 Primary open-angle glaucoma, right eye, stage unspecified 243 No No No Yes
H401111 Primary open-angle glaucoma, right eye, mild stage 243 No No No Yes
H401112 Primary open-angle glaucoma, right eye, moderate stage 243 No No No Yes
H401113 Primary open-angle glaucoma, right eye, severe stage 243 No No No Yes
H401114 Primary open-angle glaucoma, right eye, indeterminate stage 243 No No No Yes
H401120 Primary open-angle glaucoma, left eye, stage unspecified 243 No No No Yes
H401121 Primary open-angle glaucoma, left eye, mild stage 243 No No No Yes
H401122 Primary open-angle glaucoma, left eye, moderate stage 243 No No No Yes
H401123 Primary open-angle glaucoma, left eye, severe stage 243 No No No Yes
H401124 Primary open-angle glaucoma, left eye, indeterminate stage 243 No No No Yes
H401130 Primary open-angle glaucoma, bilateral, stage unspecified 243 No No No Yes
H401131 Primary open-angle glaucoma, bilateral, mild stage 243 No No No Yes
H401132 Primary open-angle glaucoma, bilateral, moderate stage 243 No No No Yes
H401133 Primary open-angle glaucoma, bilateral, severe stage 243 No No No Yes
H401134 Primary open-angle glaucoma, bilateral, indeterminate stage 243 No No No Yes
H401190 Primary open-angle glaucoma, unspecified eye, stage unspecified 243 No No No Yes
H401191 Primary open-angle glaucoma, unspecified eye, mild stage 243 No No No Yes
H401192 Primary open-angle glaucoma, unspecified eye, moderate stage 243 No No No Yes
H401193 Primary open-angle glaucoma, unspecified eye, severe stage 243 No No No Yes
H401194 Primary open-angle glaucoma, unspecified eye, indeterminate stage 243 No No No Yes
H401210 Low-tension glaucoma, right eye, stage unspecified 243 No No No Yes
H401211 Low-tension glaucoma, right eye, mild stage 243 No No No Yes
H401212 Low-tension glaucoma, right eye, moderate stage 243 No No No Yes
H401213 Low-tension glaucoma, right eye, severe stage 243 No No No Yes
H401214 Low-tension glaucoma, right eye, indeterminate stage 243 No No No Yes
H401220 Low-tension glaucoma, left eye, stage unspecified 243 No No No Yes
H401221 Low-tension glaucoma, left eye, mild stage 243 No No No Yes
H401222 Low-tension glaucoma, left eye, moderate stage 243 No No No Yes
H401223 Low-tension glaucoma, left eye, severe stage 243 No No No Yes
H401224 Low-tension glaucoma, left eye, indeterminate stage 243 No No No Yes
H401230 Low-tension glaucoma, bilateral, stage unspecified 243 No No No Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 80 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

H401231 Low-tension glaucoma, bilateral, mild stage 243 No No No Yes


H401232 Low-tension glaucoma, bilateral, moderate stage 243 No No No Yes
H401233 Low-tension glaucoma, bilateral, severe stage 243 No No No Yes
H401234 Low-tension glaucoma, bilateral, indeterminate stage 243 No No No Yes
H401290 Low-tension glaucoma, unspecified eye, stage unspecified 243 No No No Yes
H401291 Low-tension glaucoma, unspecified eye, mild stage 243 No No No Yes
H401292 Low-tension glaucoma, unspecified eye, moderate stage 243 No No No Yes
H401293 Low-tension glaucoma, unspecified eye, severe stage 243 No No No Yes
H401294 Low-tension glaucoma, unspecified eye, indeterminate stage 243 No No No Yes
H401310 Pigmentary glaucoma, right eye, stage unspecified 243 No No No Yes
H401311 Pigmentary glaucoma, right eye, mild stage 243 No No No Yes
H401312 Pigmentary glaucoma, right eye, moderate stage 243 No No No Yes
H401313 Pigmentary glaucoma, right eye, severe stage 243 No No No Yes
H401314 Pigmentary glaucoma, right eye, indeterminate stage 243 No No No Yes
H401320 Pigmentary glaucoma, left eye, stage unspecified 243 No No No Yes
H401321 Pigmentary glaucoma, left eye, mild stage 243 No No No Yes
H401322 Pigmentary glaucoma, left eye, moderate stage 243 No No No Yes
H401323 Pigmentary glaucoma, left eye, severe stage 243 No No No Yes
H401324 Pigmentary glaucoma, left eye, indeterminate stage 243 No No No Yes
H401330 Pigmentary glaucoma, bilateral, stage unspecified 243 No No No Yes
H401331 Pigmentary glaucoma, bilateral, mild stage 243 No No No Yes
H401332 Pigmentary glaucoma, bilateral, moderate stage 243 No No No Yes
H401333 Pigmentary glaucoma, bilateral, severe stage 243 No No No Yes
H401334 Pigmentary glaucoma, bilateral, indeterminate stage 243 No No No Yes
H401390 Pigmentary glaucoma, unspecified eye, stage unspecified 243 No No No Yes
H401391 Pigmentary glaucoma, unspecified eye, mild stage 243 No No No Yes
H401392 Pigmentary glaucoma, unspecified eye, moderate stage 243 No No No Yes
H401393 Pigmentary glaucoma, unspecified eye, severe stage 243 No No No Yes
H401394 Pigmentary glaucoma, unspecified eye, indeterminate stage 243 No No No Yes
H40151 Residual stage of open-angle glaucoma, right eye 243 No No No Yes
H40152 Residual stage of open-angle glaucoma, left eye 243 No No No Yes
H40153 Residual stage of open-angle glaucoma, bilateral 243 No No No Yes
H40159 Residual stage of open-angle glaucoma, unspecified eye 243 No No No Yes
H4310 Vitreous hemorrhage, unspecified eye 122 122 122 Yes Yes Yes No
H4311 Vitreous hemorrhage, right eye 122 122 122 Yes Yes Yes No
H4312 Vitreous hemorrhage, left eye 122 122 122 Yes Yes Yes No
H4313 Vitreous hemorrhage, bilateral 122 122 122 Yes Yes Yes No
H49811 Kearns-Sayre syndrome, right eye 23 23 23 41 Yes Yes Yes Yes
H49812 Kearns-Sayre syndrome, left eye 23 23 23 41 Yes Yes Yes Yes
H49813 Kearns-Sayre syndrome, bilateral 23 23 23 41 Yes Yes Yes Yes
H49819 Kearns-Sayre syndrome, unspecified eye 23 23 23 41 Yes Yes Yes Yes
I0981 Rheumatic heart failure 85 85 85 186 Yes Yes Yes Yes
I10 Essential (primary) hypertension 187 No No No Yes
I110 Hypertensive heart disease with heart failure 85 85 85 186 Yes Yes Yes Yes
I119 Hypertensive heart disease without heart failure 187 No No No Yes
I120 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease 136 136 136 187 Yes Yes Yes Yes
I120 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease 262 -- -- -- Yes
I129 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or 139 187 Yes No No Yes
unspecified chronic kidney disease
I130 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic 85 85 85 186 Yes Yes Yes Yes
kidney disease, or unspecified chronic kidney disease

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 81 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I130 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic 139 Yes -- -- --
kidney disease, or unspecified chronic kidney disease
I1310 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 139 187 Yes No No Yes
chronic kidney disease, or unspecified chronic kidney disease
I1311 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney 136 136 136 187 Yes Yes Yes Yes
disease, or end stage renal disease
I1311 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney 262 -- -- -- Yes
disease, or end stage renal disease
I132 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney 85 85 85 186 Yes Yes Yes Yes
disease, or end stage renal disease
I132 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney 136 136 136 262 Yes Yes Yes Yes
disease, or end stage renal disease
I150 Renovascular hypertension 187 No No No Yes
I151 Hypertension secondary to other renal disorders 187 No No No Yes
I152 Hypertension secondary to endocrine disorders 187 No No No Yes
I158 Other secondary hypertension 187 No No No Yes
I159 Secondary hypertension, unspecified 187 No No No Yes
I160 Hypertensive urgency 187 No No No Yes
I161 Hypertensive emergency 187 No No No Yes
I169 Hypertensive crisis, unspecified 187 No No No Yes
I200 Unstable angina 87 87 87 188 Yes Yes Yes Yes
I201 Angina pectoris with documented spasm 88 88 88 188 Yes Yes Yes Yes
I208 Other forms of angina pectoris 88 88 88 188 Yes Yes Yes Yes
I209 Angina pectoris, unspecified 88 88 88 188 Yes Yes Yes Yes
I2101 ST elevation (STEMI) myocardial infarction involving left main coronary artery 86 86 86 188 Yes Yes Yes Yes
I2102 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery 86 86 86 188 Yes Yes Yes Yes
I2109 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall 86 86 86 188 Yes Yes Yes Yes
I2111 ST elevation (STEMI) myocardial infarction involving right coronary artery 86 86 86 188 Yes Yes Yes Yes
I2119 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall 86 86 86 188 Yes Yes Yes Yes
I2121 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery 86 86 86 188 Yes Yes Yes Yes
I2129 ST elevation (STEMI) myocardial infarction involving other sites 86 86 86 188 Yes Yes Yes Yes
I213 ST elevation (STEMI) myocardial infarction of unspecified site 86 86 86 188 Yes Yes Yes Yes
I214 Non-ST elevation (NSTEMI) myocardial infarction 86 86 86 188 Yes Yes Yes Yes
I219 Acute myocardial infarction, unspecified 86 86 86 188 Yes Yes Yes Yes
I21A1 Myocardial infarction type 2 86 86 86 188 Yes Yes Yes Yes
I21A9 Other myocardial infarction type 86 86 86 188 Yes Yes Yes Yes
I220 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall 86 86 86 188 Yes Yes Yes Yes
I221 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall 86 86 86 188 Yes Yes Yes Yes
I222 Subsequent non-ST elevation (NSTEMI) myocardial infarction 86 86 86 188 Yes Yes Yes Yes
I228 Subsequent ST elevation (STEMI) myocardial infarction of other sites 86 86 86 188 Yes Yes Yes Yes
I229 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site 86 86 86 188 Yes Yes Yes Yes
I230 Hemopericardium as current complication following acute myocardial infarction 87 87 87 188 Yes Yes Yes Yes
I231 Atrial septal defect as current complication following acute myocardial infarction 87 87 87 188 Yes Yes Yes Yes
I232 Ventricular septal defect as current complication following acute myocardial infarction 87 87 87 188 Yes Yes Yes Yes
I233 Rupture of cardiac wall without hemopericardium as current complication following acute 87 87 87 188 Yes Yes Yes Yes
myocardial infarction
I234 Rupture of chordae tendineae as current complication following acute myocardial infarction 86 86 86 188 Yes Yes Yes Yes
I235 Rupture of papillary muscle as current complication following acute myocardial infarction 86 86 86 188 Yes Yes Yes Yes
I236 Thrombosis of atrium, auricular appendage, and ventricle as current complications following acute 87 87 87 188 Yes Yes Yes Yes
myocardial infarction
I237 Postinfarction angina 87 87 87 188 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 82 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I238 Other current complications following acute myocardial infarction 87 87 87 188 Yes Yes Yes Yes
I240 Acute coronary thrombosis not resulting in myocardial infarction 87 87 87 188 Yes Yes Yes Yes
I241 Dressler's syndrome 87 87 87 188 Yes Yes Yes Yes
I248 Other forms of acute ischemic heart disease 87 87 87 188 Yes Yes Yes Yes
I249 Acute ischemic heart disease, unspecified 87 87 87 188 Yes Yes Yes Yes
I2510 Atherosclerotic heart disease of native coronary artery without angina pectoris 188 No No No Yes
I25110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris 87 87 87 188 Yes Yes Yes Yes
I25111 Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm 88 88 88 188 Yes Yes Yes Yes
I25118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris 88 88 88 188 Yes Yes Yes Yes
I25119 Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris 88 88 88 188 Yes Yes Yes Yes
I252 Old myocardial infarction 188 No No No Yes
I253 Aneurysm of heart 188 No No No Yes
I2541 Coronary artery aneurysm 188 No No No Yes
I2542 Coronary artery dissection 188 No No No Yes
I255 Ischemic cardiomyopathy 188 No No No Yes
I256 Silent myocardial ischemia 188 No No No Yes
I25700 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris 87 87 87 188 Yes Yes Yes Yes
I25701 Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with 88 88 88 188 Yes Yes Yes Yes
documented spasm
I25708 Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris 88 88 88 188 Yes Yes Yes Yes
I25709 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris 88 88 88 188 Yes Yes Yes Yes
I25710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris 87 87 87 188 Yes Yes Yes Yes
I25711 Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with 88 88 88 188 Yes Yes Yes Yes
documented spasm
I25718 Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina 88 88 88 188 Yes Yes Yes Yes
pectoris
I25719 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris 88 88 88 188 Yes Yes Yes Yes
I25720 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris 87 87 87 188 Yes Yes Yes Yes
I25721 Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with 88 88 88 188 Yes Yes Yes Yes
documented spasm
I25728 Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina 88 88 88 188 Yes Yes Yes Yes
pectoris
I25729 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unspecified angina pectoris 88 88 88 188 Yes Yes Yes Yes
I25730 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina 87 87 87 188 Yes Yes Yes Yes
pectoris
I25731 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with 88 88 88 188 Yes Yes Yes Yes
documented spasm
I25738 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of 88 88 88 188 Yes Yes Yes Yes
angina pectoris
I25739 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina 88 88 88 188 Yes Yes Yes Yes
pectoris
I25750 Atherosclerosis of native coronary artery of transplanted heart with unstable angina 87 87 87 188 Yes Yes Yes Yes
I25751 Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with 88 88 88 188 Yes Yes Yes Yes
documented spasm
I25758 Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris 88 88 88 188 Yes Yes Yes Yes
I25759 Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris 88 88 88 188 Yes Yes Yes Yes
I25760 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina 87 87 87 188 Yes Yes Yes Yes
I25761 Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with 88 88 88 188 Yes Yes Yes Yes
documented spasm
I25768 Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina 88 88 88 188 Yes Yes Yes Yes
pectoris

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 83 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I25769 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina 88 88 88 188 Yes Yes Yes Yes
pectoris
I25790 Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris 87 87 87 188 Yes Yes Yes Yes
I25791 Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm 88 88 88 188 Yes Yes Yes Yes

I25798 Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris 88 88 88 188 Yes Yes Yes Yes
I25799 Atherosclerosis of other coronary artery bypass graft(s) with unspecified angina pectoris 88 88 88 188 Yes Yes Yes Yes
I25810 Atherosclerosis of coronary artery bypass graft(s) without angina pectoris 188 No No No Yes
I25811 Atherosclerosis of native coronary artery of transplanted heart without angina pectoris 188 No No No Yes
I25812 Atherosclerosis of bypass graft of coronary artery of transplanted heart without angina pectoris 188 No No No Yes
I2582 Chronic total occlusion of coronary artery 188 No No No Yes
I2583 Coronary atherosclerosis due to lipid rich plaque 188 No No No Yes
I2584 Coronary atherosclerosis due to calcified coronary lesion 188 No No No Yes
I2589 Other forms of chronic ischemic heart disease 188 No No No Yes
I259 Chronic ischemic heart disease, unspecified 188 No No No Yes
I2601 Septic pulmonary embolism with acute cor pulmonale 85 85 85 186 Yes Yes Yes Yes
I2601 Septic pulmonary embolism with acute cor pulmonale 107 107 107 215 Yes Yes Yes Yes
I2602 Saddle embolus of pulmonary artery with acute cor pulmonale 85 85 85 186 Yes Yes Yes Yes
I2602 Saddle embolus of pulmonary artery with acute cor pulmonale 107 107 107 215 Yes Yes Yes Yes
I2609 Other pulmonary embolism with acute cor pulmonale 85 85 85 186 Yes Yes Yes Yes
I2609 Other pulmonary embolism with acute cor pulmonale 107 107 107 215 Yes Yes Yes Yes
I2690 Septic pulmonary embolism without acute cor pulmonale 107 107 107 215 Yes Yes Yes Yes
I2692 Saddle embolus of pulmonary artery without acute cor pulmonale 107 107 107 215 Yes Yes Yes Yes
I2693 Single subsegmental pulmonary embolism without acute cor pulmonale 107 107 107 215 Yes Yes Yes Yes
I2694 Multiple subsegmental pulmonary emboli without acute cor pulmonale 107 107 107 215 Yes Yes Yes Yes
I2699 Other pulmonary embolism without acute cor pulmonale 107 107 107 215 Yes Yes Yes Yes
I270 Primary pulmonary hypertension 85 85 85 185 Yes Yes Yes Yes
I271 Kyphoscoliotic heart disease 85 85 85 186 Yes Yes Yes Yes
I2720 Pulmonary hypertension, unspecified 85 85 85 186 Yes Yes Yes Yes
I2721 Secondary pulmonary arterial hypertension 85 85 85 186 Yes Yes Yes Yes
I2722 Pulmonary hypertension due to left heart disease 85 85 85 186 Yes Yes Yes Yes
I2723 Pulmonary hypertension due to lung diseases and hypoxia 85 85 85 186 Yes Yes Yes Yes
I2724 Chronic thromboembolic pulmonary hypertension 85 85 85 186 Yes Yes Yes Yes
I2729 Other secondary pulmonary hypertension 85 85 85 186 Yes Yes Yes Yes
I2781 Cor pulmonale (chronic) 85 85 85 186 Yes Yes Yes Yes
I2782 Chronic pulmonary embolism 107 107 107 215 Yes Yes Yes Yes
I2783 Eisenmenger's syndrome 85 85 85 185 Yes Yes Yes Yes
I2789 Other specified pulmonary heart diseases 85 85 85 186 Yes Yes Yes Yes
I279 Pulmonary heart disease, unspecified 85 85 85 186 Yes Yes Yes Yes
I280 Arteriovenous fistula of pulmonary vessels 85 85 85 186 Yes Yes Yes Yes
I281 Aneurysm of pulmonary artery 85 85 85 186 Yes Yes Yes Yes
I288 Other diseases of pulmonary vessels 85 85 85 186 Yes Yes Yes Yes
I289 Disease of pulmonary vessels, unspecified 85 85 85 186 Yes Yes Yes Yes
I420 Dilated cardiomyopathy 85 85 85 186 Yes Yes Yes Yes
I421 Obstructive hypertrophic cardiomyopathy 85 85 85 186 Yes Yes Yes Yes
I422 Other hypertrophic cardiomyopathy 85 85 85 186 Yes Yes Yes Yes
I423 Endomyocardial (eosinophilic) disease 85 85 85 186 Yes Yes Yes Yes
I424 Endocardial fibroelastosis 85 85 85 186 Yes Yes Yes Yes
I425 Other restrictive cardiomyopathy 85 85 85 186 Yes Yes Yes Yes
I426 Alcoholic cardiomyopathy 85 85 85 186 Yes Yes Yes Yes
I427 Cardiomyopathy due to drug and external agent 85 85 85 186 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 84 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I428 Other cardiomyopathies 85 85 85 186 Yes Yes Yes Yes


I429 Cardiomyopathy, unspecified 85 85 85 186 Yes Yes Yes Yes
I43 Cardiomyopathy in diseases classified elsewhere 85 85 85 186 Yes Yes Yes Yes
I442 Atrioventricular block, complete 96 96 96 Yes Yes Yes No
I462 Cardiac arrest due to underlying cardiac condition 84 84 84 Yes Yes Yes No
I468 Cardiac arrest due to other underlying condition 84 84 84 Yes Yes Yes No
I469 Cardiac arrest, cause unspecified 84 84 84 Yes Yes Yes No
I470 Re-entry ventricular arrhythmia 96 96 96 Yes Yes Yes No
I471 Supraventricular tachycardia 96 96 96 193 Yes Yes Yes Yes
I472 Ventricular tachycardia 96 96 96 Yes Yes Yes No
I479 Paroxysmal tachycardia, unspecified 96 96 96 193 Yes Yes Yes Yes
I480 Paroxysmal atrial fibrillation 96 96 96 193 Yes Yes Yes Yes
I4811 Longstanding persistent atrial fibrillation 96 96 96 193 Yes Yes Yes Yes
I4819 Other persistent atrial fibrillation 96 96 96 193 Yes Yes Yes Yes
I4820 Chronic atrial fibrillation, unspecified 96 96 96 193 Yes Yes Yes Yes
I4821 Permanent atrial fibrillation 96 96 96 193 Yes Yes Yes Yes
I483 Typical atrial flutter 96 96 96 193 Yes Yes Yes Yes
I484 Atypical atrial flutter 96 96 96 193 Yes Yes Yes Yes
I4891 Unspecified atrial fibrillation 96 96 96 193 Yes Yes Yes Yes
I4892 Unspecified atrial flutter 96 96 96 193 Yes Yes Yes Yes
I4901 Ventricular fibrillation 84 84 84 Yes Yes Yes No
I4902 Ventricular flutter 84 84 84 Yes Yes Yes No
I492 Junctional premature depolarization 96 96 96 193 Yes Yes Yes Yes
I495 Sick sinus syndrome 96 96 96 Yes Yes Yes No
I501 Left ventricular failure, unspecified 85 85 85 186 Yes Yes Yes Yes
I5020 Unspecified systolic (congestive) heart failure 85 85 85 186 Yes Yes Yes Yes
I5021 Acute systolic (congestive) heart failure 85 85 85 186 Yes Yes Yes Yes
I5022 Chronic systolic (congestive) heart failure 85 85 85 186 Yes Yes Yes Yes
I5023 Acute on chronic systolic (congestive) heart failure 85 85 85 186 Yes Yes Yes Yes
I5030 Unspecified diastolic (congestive) heart failure 85 85 85 186 Yes Yes Yes Yes
I5031 Acute diastolic (congestive) heart failure 85 85 85 186 Yes Yes Yes Yes
I5032 Chronic diastolic (congestive) heart failure 85 85 85 186 Yes Yes Yes Yes
I5033 Acute on chronic diastolic (congestive) heart failure 85 85 85 186 Yes Yes Yes Yes
I5040 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure 85 85 85 186 Yes Yes Yes Yes
I5041 Acute combined systolic (congestive) and diastolic (congestive) heart failure 85 85 85 186 Yes Yes Yes Yes
I5042 Chronic combined systolic (congestive) and diastolic (congestive) heart failure 85 85 85 186 Yes Yes Yes Yes
I5043 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure 85 85 85 186 Yes Yes Yes Yes
I50810 Right heart failure, unspecified 85 85 85 186 Yes Yes Yes Yes
I50811 Acute right heart failure 85 85 85 186 Yes Yes Yes Yes
I50812 Chronic right heart failure 85 85 85 186 Yes Yes Yes Yes
I50813 Acute on chronic right heart failure 85 85 85 186 Yes Yes Yes Yes
I50814 Right heart failure due to left heart failure 85 85 85 186 Yes Yes Yes Yes
I5082 Biventricular heart failure 85 85 85 186 Yes Yes Yes Yes
I5083 High output heart failure 85 85 85 186 Yes Yes Yes Yes
I5084 End stage heart failure 85 85 85 186 Yes Yes Yes Yes
I5089 Other heart failure 85 85 85 186 Yes Yes Yes Yes
I509 Heart failure, unspecified 85 85 85 186 Yes Yes Yes Yes
I511 Rupture of chordae tendineae, not elsewhere classified 86 86 86 188 Yes Yes Yes Yes
I512 Rupture of papillary muscle, not elsewhere classified 86 86 86 188 Yes Yes Yes Yes
I514 Myocarditis, unspecified 85 85 85 186 Yes Yes Yes Yes
I515 Myocardial degeneration 85 85 85 186 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 85 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I6000 Nontraumatic subarachnoid hemorrhage from unspecified carotid siphon and bifurcation 99 99 99 Yes Yes Yes No
I6001 Nontraumatic subarachnoid hemorrhage from right carotid siphon and bifurcation 99 99 99 Yes Yes Yes No
I6002 Nontraumatic subarachnoid hemorrhage from left carotid siphon and bifurcation 99 99 99 Yes Yes Yes No
I6010 Nontraumatic subarachnoid hemorrhage from unspecified middle cerebral artery 99 99 99 Yes Yes Yes No
I6011 Nontraumatic subarachnoid hemorrhage from right middle cerebral artery 99 99 99 Yes Yes Yes No
I6012 Nontraumatic subarachnoid hemorrhage from left middle cerebral artery 99 99 99 Yes Yes Yes No
I602 Nontraumatic subarachnoid hemorrhage from anterior communicating artery 99 99 99 Yes Yes Yes No
I6030 Nontraumatic subarachnoid hemorrhage from unspecified posterior communicating artery 99 99 99 Yes Yes Yes No
I6031 Nontraumatic subarachnoid hemorrhage from right posterior communicating artery 99 99 99 Yes Yes Yes No
I6032 Nontraumatic subarachnoid hemorrhage from left posterior communicating artery 99 99 99 Yes Yes Yes No
I604 Nontraumatic subarachnoid hemorrhage from basilar artery 99 99 99 Yes Yes Yes No
I6050 Nontraumatic subarachnoid hemorrhage from unspecified vertebral artery 99 99 99 Yes Yes Yes No
I6051 Nontraumatic subarachnoid hemorrhage from right vertebral artery 99 99 99 Yes Yes Yes No
I6052 Nontraumatic subarachnoid hemorrhage from left vertebral artery 99 99 99 Yes Yes Yes No
I606 Nontraumatic subarachnoid hemorrhage from other intracranial arteries 99 99 99 Yes Yes Yes No
I607 Nontraumatic subarachnoid hemorrhage from unspecified intracranial artery 99 99 99 Yes Yes Yes No
I608 Other nontraumatic subarachnoid hemorrhage 99 99 99 Yes Yes Yes No
I609 Nontraumatic subarachnoid hemorrhage, unspecified 99 99 99 Yes Yes Yes No
I610 Nontraumatic intracerebral hemorrhage in hemisphere, subcortical 99 99 99 Yes Yes Yes No
I611 Nontraumatic intracerebral hemorrhage in hemisphere, cortical 99 99 99 Yes Yes Yes No
I612 Nontraumatic intracerebral hemorrhage in hemisphere, unspecified 99 99 99 Yes Yes Yes No
I613 Nontraumatic intracerebral hemorrhage in brain stem 99 99 99 Yes Yes Yes No
I614 Nontraumatic intracerebral hemorrhage in cerebellum 99 99 99 Yes Yes Yes No
I615 Nontraumatic intracerebral hemorrhage, intraventricular 99 99 99 Yes Yes Yes No
I616 Nontraumatic intracerebral hemorrhage, multiple localized 99 99 99 Yes Yes Yes No
I618 Other nontraumatic intracerebral hemorrhage 99 99 99 Yes Yes Yes No
I619 Nontraumatic intracerebral hemorrhage, unspecified 99 99 99 Yes Yes Yes No
I6200 Nontraumatic subdural hemorrhage, unspecified 99 99 99 Yes Yes Yes No
I6201 Nontraumatic acute subdural hemorrhage 99 99 99 Yes Yes Yes No
I6202 Nontraumatic subacute subdural hemorrhage 99 99 99 Yes Yes Yes No
I6203 Nontraumatic chronic subdural hemorrhage 99 99 99 Yes Yes Yes No
I621 Nontraumatic extradural hemorrhage 99 99 99 Yes Yes Yes No
I629 Nontraumatic intracranial hemorrhage, unspecified 99 99 99 Yes Yes Yes No
I6300 Cerebral infarction due to thrombosis of unspecified precerebral artery 100 100 100 206 Yes Yes Yes Yes
I63011 Cerebral infarction due to thrombosis of right vertebral artery 100 100 100 206 Yes Yes Yes Yes
I63012 Cerebral infarction due to thrombosis of left vertebral artery 100 100 100 206 Yes Yes Yes Yes
I63013 Cerebral infarction due to thrombosis of bilateral vertebral arteries 100 100 100 206 Yes Yes Yes Yes
I63019 Cerebral infarction due to thrombosis of unspecified vertebral artery 100 100 100 206 Yes Yes Yes Yes
I6302 Cerebral infarction due to thrombosis of basilar artery 100 100 100 206 Yes Yes Yes Yes
I63031 Cerebral infarction due to thrombosis of right carotid artery 100 100 100 206 Yes Yes Yes Yes
I63032 Cerebral infarction due to thrombosis of left carotid artery 100 100 100 206 Yes Yes Yes Yes
I63033 Cerebral infarction due to thrombosis of bilateral carotid arteries 100 100 100 206 Yes Yes Yes Yes
I63039 Cerebral infarction due to thrombosis of unspecified carotid artery 100 100 100 206 Yes Yes Yes Yes
I6309 Cerebral infarction due to thrombosis of other precerebral artery 100 100 100 206 Yes Yes Yes Yes
I6310 Cerebral infarction due to embolism of unspecified precerebral artery 100 100 100 206 Yes Yes Yes Yes
I63111 Cerebral infarction due to embolism of right vertebral artery 100 100 100 206 Yes Yes Yes Yes
I63112 Cerebral infarction due to embolism of left vertebral artery 100 100 100 206 Yes Yes Yes Yes
I63113 Cerebral infarction due to embolism of bilateral vertebral arteries 100 100 100 206 Yes Yes Yes Yes
I63119 Cerebral infarction due to embolism of unspecified vertebral artery 100 100 100 206 Yes Yes Yes Yes
I6312 Cerebral infarction due to embolism of basilar artery 100 100 100 206 Yes Yes Yes Yes
I63131 Cerebral infarction due to embolism of right carotid artery 100 100 100 206 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 86 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I63132 Cerebral infarction due to embolism of left carotid artery 100 100 100 206 Yes Yes Yes Yes
I63133 Cerebral infarction due to embolism of bilateral carotid arteries 100 100 100 206 Yes Yes Yes Yes
I63139 Cerebral infarction due to embolism of unspecified carotid artery 100 100 100 206 Yes Yes Yes Yes
I6319 Cerebral infarction due to embolism of other precerebral artery 100 100 100 206 Yes Yes Yes Yes
I6320 Cerebral infarction due to unspecified occlusion or stenosis of unspecified precerebral arteries 100 100 100 206 Yes Yes Yes Yes
I63211 Cerebral infarction due to unspecified occlusion or stenosis of right vertebral artery 100 100 100 206 Yes Yes Yes Yes
I63212 Cerebral infarction due to unspecified occlusion or stenosis of left vertebral artery 100 100 100 206 Yes Yes Yes Yes
I63213 Cerebral infarction due to unspecified occlusion or stenosis of bilateral vertebral arteries 100 100 100 206 Yes Yes Yes Yes
I63219 Cerebral infarction due to unspecified occlusion or stenosis of unspecified vertebral artery 100 100 100 206 Yes Yes Yes Yes
I6322 Cerebral infarction due to unspecified occlusion or stenosis of basilar artery 100 100 100 206 Yes Yes Yes Yes
I63231 Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries 100 100 100 206 Yes Yes Yes Yes
I63232 Cerebral infarction due to unspecified occlusion or stenosis of left carotid arteries 100 100 100 206 Yes Yes Yes Yes
I63233 Cerebral infarction due to unspecified occlusion or stenosis of bilateral carotid arteries 100 100 100 206 Yes Yes Yes Yes
I63239 Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid artery 100 100 100 206 Yes Yes Yes Yes
I6329 Cerebral infarction due to unspecified occlusion or stenosis of other precerebral arteries 100 100 100 206 Yes Yes Yes Yes
I6330 Cerebral infarction due to thrombosis of unspecified cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63311 Cerebral infarction due to thrombosis of right middle cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63312 Cerebral infarction due to thrombosis of left middle cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63313 Cerebral infarction due to thrombosis of bilateral middle cerebral arteries 100 100 100 206 Yes Yes Yes Yes
I63319 Cerebral infarction due to thrombosis of unspecified middle cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63321 Cerebral infarction due to thrombosis of right anterior cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63322 Cerebral infarction due to thrombosis of left anterior cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63323 Cerebral infarction due to thrombosis of bilateral anterior cerebral arteries 100 100 100 206 Yes Yes Yes Yes
I63329 Cerebral infarction due to thrombosis of unspecified anterior cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63331 Cerebral infarction due to thrombosis of right posterior cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63332 Cerebral infarction due to thrombosis of left posterior cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63333 Cerebral infarction due to thrombosis of bilateral posterior cerebral arteries 100 100 100 206 Yes Yes Yes Yes
I63339 Cerebral infarction due to thrombosis of unspecified posterior cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63341 Cerebral infarction due to thrombosis of right cerebellar artery 100 100 100 206 Yes Yes Yes Yes
I63342 Cerebral infarction due to thrombosis of left cerebellar artery 100 100 100 206 Yes Yes Yes Yes
I63343 Cerebral infarction due to thrombosis of bilateral cerebellar arteries 100 100 100 206 Yes Yes Yes Yes
I63349 Cerebral infarction due to thrombosis of unspecified cerebellar artery 100 100 100 206 Yes Yes Yes Yes
I6339 Cerebral infarction due to thrombosis of other cerebral artery 100 100 100 206 Yes Yes Yes Yes
I6340 Cerebral infarction due to embolism of unspecified cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63411 Cerebral infarction due to embolism of right middle cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63412 Cerebral infarction due to embolism of left middle cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63413 Cerebral infarction due to embolism of bilateral middle cerebral arteries 100 100 100 206 Yes Yes Yes Yes
I63419 Cerebral infarction due to embolism of unspecified middle cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63421 Cerebral infarction due to embolism of right anterior cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63422 Cerebral infarction due to embolism of left anterior cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63423 Cerebral infarction due to embolism of bilateral anterior cerebral arteries 100 100 100 206 Yes Yes Yes Yes
I63429 Cerebral infarction due to embolism of unspecified anterior cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63431 Cerebral infarction due to embolism of right posterior cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63432 Cerebral infarction due to embolism of left posterior cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63433 Cerebral infarction due to embolism of bilateral posterior cerebral arteries 100 100 100 206 Yes Yes Yes Yes
I63439 Cerebral infarction due to embolism of unspecified posterior cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63441 Cerebral infarction due to embolism of right cerebellar artery 100 100 100 206 Yes Yes Yes Yes
I63442 Cerebral infarction due to embolism of left cerebellar artery 100 100 100 206 Yes Yes Yes Yes
I63443 Cerebral infarction due to embolism of bilateral cerebellar arteries 100 100 100 206 Yes Yes Yes Yes
I63449 Cerebral infarction due to embolism of unspecified cerebellar artery 100 100 100 206 Yes Yes Yes Yes
I6349 Cerebral infarction due to embolism of other cerebral artery 100 100 100 206 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 87 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I6350 Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63511 Cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63512 Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63513 Cerebral infarction due to unspecified occlusion or stenosis of bilateral middle cerebral arteries 100 100 100 206 Yes Yes Yes Yes
I63519 Cerebral infarction due to unspecified occlusion or stenosis of unspecified middle cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63521 Cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63522 Cerebral infarction due to unspecified occlusion or stenosis of left anterior cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63523 Cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior cerebral arteries 100 100 100 206 Yes Yes Yes Yes
I63529 Cerebral infarction due to unspecified occlusion or stenosis of unspecified anterior cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63531 Cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63532 Cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63533 Cerebral infarction due to unspecified occlusion or stenosis of bilateral posterior cerebral arteries 100 100 100 206 Yes Yes Yes Yes
I63539 Cerebral infarction due to unspecified occlusion or stenosis of unspecified posterior cerebral artery 100 100 100 206 Yes Yes Yes Yes
I63541 Cerebral infarction due to unspecified occlusion or stenosis of right cerebellar artery 100 100 100 206 Yes Yes Yes Yes
I63542 Cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery 100 100 100 206 Yes Yes Yes Yes
I63543 Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries 100 100 100 206 Yes Yes Yes Yes
I63549 Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebellar artery 100 100 100 206 Yes Yes Yes Yes
I6359 Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery 100 100 100 206 Yes Yes Yes Yes
I636 Cerebral infarction due to cerebral venous thrombosis, nonpyogenic 100 100 100 206 Yes Yes Yes Yes
I6381 Other cerebral infarction due to occlusion or stenosis of small artery 100 100 100 206 Yes Yes Yes Yes
I6389 Other cerebral infarction 100 100 100 206 Yes Yes Yes Yes
I639 Cerebral infarction, unspecified 100 100 100 206 Yes Yes Yes Yes
I6501 Occlusion and stenosis of right vertebral artery 206 No No No Yes
I6502 Occlusion and stenosis of left vertebral artery 206 No No No Yes
I6503 Occlusion and stenosis of bilateral vertebral arteries 206 No No No Yes
I6509 Occlusion and stenosis of unspecified vertebral artery 206 No No No Yes
I651 Occlusion and stenosis of basilar artery 206 No No No Yes
I6521 Occlusion and stenosis of right carotid artery 206 No No No Yes
I6522 Occlusion and stenosis of left carotid artery 206 No No No Yes
I6523 Occlusion and stenosis of bilateral carotid arteries 206 No No No Yes
I6529 Occlusion and stenosis of unspecified carotid artery 206 No No No Yes
I658 Occlusion and stenosis of other precerebral arteries 206 No No No Yes
I659 Occlusion and stenosis of unspecified precerebral artery 206 No No No Yes
I6601 Occlusion and stenosis of right middle cerebral artery 206 No No No Yes
I6602 Occlusion and stenosis of left middle cerebral artery 206 No No No Yes
I6603 Occlusion and stenosis of bilateral middle cerebral arteries 206 No No No Yes
I6609 Occlusion and stenosis of unspecified middle cerebral artery 206 No No No Yes
I6611 Occlusion and stenosis of right anterior cerebral artery 206 No No No Yes
I6612 Occlusion and stenosis of left anterior cerebral artery 206 No No No Yes
I6613 Occlusion and stenosis of bilateral anterior cerebral arteries 206 No No No Yes
I6619 Occlusion and stenosis of unspecified anterior cerebral artery 206 No No No Yes
I6621 Occlusion and stenosis of right posterior cerebral artery 206 No No No Yes
I6622 Occlusion and stenosis of left posterior cerebral artery 206 No No No Yes
I6623 Occlusion and stenosis of bilateral posterior cerebral arteries 206 No No No Yes
I6629 Occlusion and stenosis of unspecified posterior cerebral artery 206 No No No Yes
I663 Occlusion and stenosis of cerebellar arteries 206 No No No Yes
I668 Occlusion and stenosis of other cerebral arteries 206 No No No Yes
I669 Occlusion and stenosis of unspecified cerebral artery 206 No No No Yes
I670 Dissection of cerebral arteries, nonruptured 107 107 107 Yes Yes Yes No
I672 Cerebral atherosclerosis 206 No No No Yes
I673 Progressive vascular leukoencephalopathy 52 52 112 Yes No Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 88 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I674 Hypertensive encephalopathy 187 No No No Yes


I675 Moyamoya disease 206 No No No Yes
I676 Nonpyogenic thrombosis of intracranial venous system 206 No No No Yes
I677 Cerebral arteritis, not elsewhere classified 206 No No No Yes
I6781 Acute cerebrovascular insufficiency 206 No No No Yes
I6782 Cerebral ischemia 206 No No No Yes
I67841 Reversible cerebrovascular vasoconstriction syndrome 206 No No No Yes
I67848 Other cerebrovascular vasospasm and vasoconstriction 206 No No No Yes
I67850 Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy 206 No No No Yes
I67858 Other hereditary cerebrovascular disease 206 No No No Yes
I6789 Other cerebrovascular disease 206 No No No Yes
I679 Cerebrovascular disease, unspecified 206 No No No Yes
I680 Cerebral amyloid angiopathy 206 No No No Yes
I682 Cerebral arteritis in other diseases classified elsewhere 206 No No No Yes
I688 Other cerebrovascular disorders in diseases classified elsewhere 206 No No No Yes
I69031 Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting right 104 104 104 Yes Yes Yes No
dominant side
I69032 Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting left dominant 104 104 104 Yes Yes Yes No
side
I69033 Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting right non- 104 104 104 Yes Yes Yes No
dominant side
I69034 Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting left non- 104 104 104 Yes Yes Yes No
dominant side
I69039 Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting unspecified 104 104 104 Yes Yes Yes No
side
I69041 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting right 104 104 104 Yes Yes Yes No
dominant side
I69042 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left dominant 104 104 104 Yes Yes Yes No
side
I69043 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting right non- 104 104 104 Yes Yes Yes No
dominant side
I69044 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left non- 104 104 104 Yes Yes Yes No
dominant side
I69049 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting unspecified 104 104 104 Yes Yes Yes No
side
I69051 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right 103 103 103 Yes Yes Yes No
dominant side
I69052 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left 103 103 103 Yes Yes Yes No
dominant side
I69053 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right non- 103 103 103 Yes Yes Yes No
dominant side
I69054 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non- 103 103 103 Yes Yes Yes No
dominant side
I69059 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting unspecified 103 103 103 Yes Yes Yes No
side
I69061 Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting right dominant 104 104 104 Yes Yes Yes No
side
I69062 Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting left dominant 104 104 104 Yes Yes Yes No
side
I69063 Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting right non- 104 104 104 Yes Yes Yes No
dominant side

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 89 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I69064 Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting left non- 104 104 104 Yes Yes Yes No
dominant side
I69065 Other paralytic syndrome following nontraumatic subarachnoid hemorrhage, bilateral 104 104 104 Yes Yes Yes No
I69069 Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting unspecified 104 104 104 Yes Yes Yes No
side
I69131 Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting right dominant 104 104 104 Yes Yes Yes No
side
I69132 Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting left dominant 104 104 104 Yes Yes Yes No
side
I69133 Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting right non- 104 104 104 Yes Yes Yes No
dominant side
I69134 Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting left non- 104 104 104 Yes Yes Yes No
dominant side
I69139 Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting unspecified 104 104 104 Yes Yes Yes No
side
I69141 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting right dominant 104 104 104 Yes Yes Yes No
side
I69142 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting left dominant 104 104 104 Yes Yes Yes No
side
I69143 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting right non- 104 104 104 Yes Yes Yes No
dominant side
I69144 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting left non- 104 104 104 Yes Yes Yes No
dominant side
I69149 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting unspecified 104 104 104 Yes Yes Yes No
side
I69151 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right 103 103 103 Yes Yes Yes No
dominant side
I69152 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left 103 103 103 Yes Yes Yes No
dominant side
I69153 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right non- 103 103 103 Yes Yes Yes No
dominant side
I69154 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non- 103 103 103 Yes Yes Yes No
dominant side
I69159 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting unspecified 103 103 103 Yes Yes Yes No
side
I69161 Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting right dominant 104 104 104 Yes Yes Yes No
side
I69162 Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting left dominant 104 104 104 Yes Yes Yes No
side
I69163 Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting right non- 104 104 104 Yes Yes Yes No
dominant side
I69164 Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting left non- 104 104 104 Yes Yes Yes No
dominant side
I69165 Other paralytic syndrome following nontraumatic intracerebral hemorrhage, bilateral 104 104 104 Yes Yes Yes No
I69169 Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting unspecified 104 104 104 Yes Yes Yes No
side
I69231 Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting right 104 104 104 Yes Yes Yes No
dominant side
I69232 Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting left 104 104 104 Yes Yes Yes No
dominant side

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 90 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I69233 Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting right non- 104 104 104 Yes Yes Yes No
dominant side
I69234 Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting left non- 104 104 104 Yes Yes Yes No
dominant side
I69239 Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting 104 104 104 Yes Yes Yes No
unspecified side
I69241 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting right 104 104 104 Yes Yes Yes No
dominant side
I69242 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting left 104 104 104 Yes Yes Yes No
dominant side
I69243 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting right non- 104 104 104 Yes Yes Yes No
dominant side
I69244 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting left non- 104 104 104 Yes Yes Yes No
dominant side
I69249 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting 104 104 104 Yes Yes Yes No
unspecified side
I69251 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right 103 103 103 Yes Yes Yes No
dominant side
I69252 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left 103 103 103 Yes Yes Yes No
dominant side
I69253 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right 103 103 103 Yes Yes Yes No
non-dominant side
I69254 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left 103 103 103 Yes Yes Yes No
non-dominant side
I69259 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting 103 103 103 Yes Yes Yes No
unspecified side
I69261 Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting right 104 104 104 Yes Yes Yes No
dominant side
I69262 Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting left 104 104 104 Yes Yes Yes No
dominant side
I69263 Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting right non- 104 104 104 Yes Yes Yes No
dominant side
I69264 Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting left non- 104 104 104 Yes Yes Yes No
dominant side
I69265 Other paralytic syndrome following other nontraumatic intracranial hemorrhage, bilateral 104 104 104 Yes Yes Yes No
I69269 Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting 104 104 104 Yes Yes Yes No
unspecified side
I69331 Monoplegia of upper limb following cerebral infarction affecting right dominant side 104 104 104 Yes Yes Yes No
I69332 Monoplegia of upper limb following cerebral infarction affecting left dominant side 104 104 104 Yes Yes Yes No
I69333 Monoplegia of upper limb following cerebral infarction affecting right non-dominant side 104 104 104 Yes Yes Yes No
I69334 Monoplegia of upper limb following cerebral infarction affecting left non-dominant side 104 104 104 Yes Yes Yes No
I69339 Monoplegia of upper limb following cerebral infarction affecting unspecified side 104 104 104 Yes Yes Yes No
I69341 Monoplegia of lower limb following cerebral infarction affecting right dominant side 104 104 104 Yes Yes Yes No
I69342 Monoplegia of lower limb following cerebral infarction affecting left dominant side 104 104 104 Yes Yes Yes No
I69343 Monoplegia of lower limb following cerebral infarction affecting right non-dominant side 104 104 104 Yes Yes Yes No
I69344 Monoplegia of lower limb following cerebral infarction affecting left non-dominant side 104 104 104 Yes Yes Yes No
I69349 Monoplegia of lower limb following cerebral infarction affecting unspecified side 104 104 104 Yes Yes Yes No
I69351 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side 103 103 103 Yes Yes Yes No
I69352 Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side 103 103 103 Yes Yes Yes No
I69353 Hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side 103 103 103 Yes Yes Yes No
I69354 Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side 103 103 103 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 91 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I69359 Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side 103 103 103 Yes Yes Yes No
I69361 Other paralytic syndrome following cerebral infarction affecting right dominant side 104 104 104 Yes Yes Yes No
I69362 Other paralytic syndrome following cerebral infarction affecting left dominant side 104 104 104 Yes Yes Yes No
I69363 Other paralytic syndrome following cerebral infarction affecting right non-dominant side 104 104 104 Yes Yes Yes No
I69364 Other paralytic syndrome following cerebral infarction affecting left non-dominant side 104 104 104 Yes Yes Yes No
I69365 Other paralytic syndrome following cerebral infarction, bilateral 104 104 104 Yes Yes Yes No
I69369 Other paralytic syndrome following cerebral infarction affecting unspecified side 104 104 104 Yes Yes Yes No
I69831 Monoplegia of upper limb following other cerebrovascular disease affecting right dominant side 104 104 104 Yes Yes Yes No
I69832 Monoplegia of upper limb following other cerebrovascular disease affecting left dominant side 104 104 104 Yes Yes Yes No
I69833 Monoplegia of upper limb following other cerebrovascular disease affecting right non-dominant side 104 104 104 Yes Yes Yes No
I69834 Monoplegia of upper limb following other cerebrovascular disease affecting left non-dominant side 104 104 104 Yes Yes Yes No
I69839 Monoplegia of upper limb following other cerebrovascular disease affecting unspecified side 104 104 104 Yes Yes Yes No
I69841 Monoplegia of lower limb following other cerebrovascular disease affecting right dominant side 104 104 104 Yes Yes Yes No
I69842 Monoplegia of lower limb following other cerebrovascular disease affecting left dominant side 104 104 104 Yes Yes Yes No
I69843 Monoplegia of lower limb following other cerebrovascular disease affecting right non-dominant side 104 104 104 Yes Yes Yes No
I69844 Monoplegia of lower limb following other cerebrovascular disease affecting left non-dominant side 104 104 104 Yes Yes Yes No
I69849 Monoplegia of lower limb following other cerebrovascular disease affecting unspecified side 104 104 104 Yes Yes Yes No
I69851 Hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side 103 103 103 Yes Yes Yes No
I69852 Hemiplegia and hemiparesis following other cerebrovascular disease affecting left dominant side 103 103 103 Yes Yes Yes No
I69853 Hemiplegia and hemiparesis following other cerebrovascular disease affecting right non-dominant 103 103 103 Yes Yes Yes No
side
I69854 Hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side 103 103 103 Yes Yes Yes No

I69859 Hemiplegia and hemiparesis following other cerebrovascular disease affecting unspecified side 103 103 103 Yes Yes Yes No
I69861 Other paralytic syndrome following other cerebrovascular disease affecting right dominant side 104 104 104 Yes Yes Yes No
I69862 Other paralytic syndrome following other cerebrovascular disease affecting left dominant side 104 104 104 Yes Yes Yes No
I69863 Other paralytic syndrome following other cerebrovascular disease affecting right non-dominant side 104 104 104 Yes Yes Yes No
I69864 Other paralytic syndrome following other cerebrovascular disease affecting left non-dominant side 104 104 104 Yes Yes Yes No
I69865 Other paralytic syndrome following other cerebrovascular disease, bilateral 104 104 104 Yes Yes Yes No
I69869 Other paralytic syndrome following other cerebrovascular disease affecting unspecified side 104 104 104 Yes Yes Yes No
I69931 Monoplegia of upper limb following unspecified cerebrovascular disease affecting right dominant 104 104 104 Yes Yes Yes No
side
I69932 Monoplegia of upper limb following unspecified cerebrovascular disease affecting left dominant side 104 104 104 Yes Yes Yes No
I69933 Monoplegia of upper limb following unspecified cerebrovascular disease affecting right non- 104 104 104 Yes Yes Yes No
dominant side
I69934 Monoplegia of upper limb following unspecified cerebrovascular disease affecting left non-dominant 104 104 104 Yes Yes Yes No
side
I69939 Monoplegia of upper limb following unspecified cerebrovascular disease affecting unspecified side 104 104 104 Yes Yes Yes No
I69941 Monoplegia of lower limb following unspecified cerebrovascular disease affecting right dominant 104 104 104 Yes Yes Yes No
side
I69942 Monoplegia of lower limb following unspecified cerebrovascular disease affecting left dominant side 104 104 104 Yes Yes Yes No
I69943 Monoplegia of lower limb following unspecified cerebrovascular disease affecting right non- 104 104 104 Yes Yes Yes No
dominant side
I69944 Monoplegia of lower limb following unspecified cerebrovascular disease affecting left non-dominant 104 104 104 Yes Yes Yes No
side
I69949 Monoplegia of lower limb following unspecified cerebrovascular disease affecting unspecified side 104 104 104 Yes Yes Yes No
I69951 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant 103 103 103 Yes Yes Yes No
side
I69952 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant 103 103 103 Yes Yes Yes No
side

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 92 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I69953 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non- 103 103 103 Yes Yes Yes No
dominant side
I69954 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non- 103 103 103 Yes Yes Yes No
dominant side
I69959 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side 103 103 103 Yes Yes Yes No
I69961 Other paralytic syndrome following unspecified cerebrovascular disease affecting right dominant side 104 104 104 Yes Yes Yes No

I69962 Other paralytic syndrome following unspecified cerebrovascular disease affecting left dominant side 104 104 104 Yes Yes Yes No
I69963 Other paralytic syndrome following unspecified cerebrovascular disease affecting right non- 104 104 104 Yes Yes Yes No
dominant side
I69964 Other paralytic syndrome following unspecified cerebrovascular disease affecting left non-dominant 104 104 104 Yes Yes Yes No
side
I69965 Other paralytic syndrome following unspecified cerebrovascular disease, bilateral 104 104 104 Yes Yes Yes No
I69969 Other paralytic syndrome following unspecified cerebrovascular disease affecting unspecified side 104 104 104 Yes Yes Yes No
I700 Atherosclerosis of aorta 108 108 108 216 Yes Yes Yes Yes
I701 Atherosclerosis of renal artery 108 108 108 216 Yes Yes Yes Yes
I70201 Unspecified atherosclerosis of native arteries of extremities, right leg 108 108 108 216 Yes Yes Yes Yes
I70202 Unspecified atherosclerosis of native arteries of extremities, left leg 108 108 108 216 Yes Yes Yes Yes
I70203 Unspecified atherosclerosis of native arteries of extremities, bilateral legs 108 108 108 216 Yes Yes Yes Yes
I70208 Unspecified atherosclerosis of native arteries of extremities, other extremity 108 108 108 216 Yes Yes Yes Yes
I70209 Unspecified atherosclerosis of native arteries of extremities, unspecified extremity 108 108 108 216 Yes Yes Yes Yes
I70211 Atherosclerosis of native arteries of extremities with intermittent claudication, right leg 108 108 108 216 Yes Yes Yes Yes
I70212 Atherosclerosis of native arteries of extremities with intermittent claudication, left leg 108 108 108 216 Yes Yes Yes Yes
I70213 Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs 108 108 108 216 Yes Yes Yes Yes
I70218 Atherosclerosis of native arteries of extremities with intermittent claudication, other extremity 108 108 108 216 Yes Yes Yes Yes
I70219 Atherosclerosis of native arteries of extremities with intermittent claudication, unspecified extremity 108 108 108 216 Yes Yes Yes Yes
I70221 Atherosclerosis of native arteries of extremities with rest pain, right leg 108 108 108 216 Yes Yes Yes Yes
I70222 Atherosclerosis of native arteries of extremities with rest pain, left leg 108 108 108 216 Yes Yes Yes Yes
I70223 Atherosclerosis of native arteries of extremities with rest pain, bilateral legs 108 108 108 216 Yes Yes Yes Yes
I70228 Atherosclerosis of native arteries of extremities with rest pain, other extremity 108 108 108 216 Yes Yes Yes Yes
I70229 Atherosclerosis of native arteries of extremities with rest pain, unspecified extremity 108 108 108 216 Yes Yes Yes Yes
I70231 Atherosclerosis of native arteries of right leg with ulceration of thigh 106 106 106 311 Yes Yes Yes Yes
I70231 Atherosclerosis of native arteries of right leg with ulceration of thigh 161 161 161 Yes Yes Yes --
I70232 Atherosclerosis of native arteries of right leg with ulceration of calf 106 106 106 311 Yes Yes Yes Yes
I70232 Atherosclerosis of native arteries of right leg with ulceration of calf 161 161 161 Yes Yes Yes --
I70233 Atherosclerosis of native arteries of right leg with ulceration of ankle 106 106 106 311 Yes Yes Yes Yes
I70233 Atherosclerosis of native arteries of right leg with ulceration of ankle 161 161 161 Yes Yes Yes --
I70234 Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot 106 106 106 311 Yes Yes Yes Yes
I70234 Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot 161 161 161 Yes Yes Yes --
I70235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot 106 106 106 311 Yes Yes Yes Yes
I70235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot 161 161 161 Yes Yes Yes --
I70238 Atherosclerosis of native arteries of right leg with ulceration of other part of lower leg 106 106 106 311 Yes Yes Yes Yes
I70238 Atherosclerosis of native arteries of right leg with ulceration of other part of lower leg 161 161 161 Yes Yes Yes --
I70239 Atherosclerosis of native arteries of right leg with ulceration of unspecified site 106 106 106 311 Yes Yes Yes Yes
I70239 Atherosclerosis of native arteries of right leg with ulceration of unspecified site 161 161 161 Yes Yes Yes --
I70241 Atherosclerosis of native arteries of left leg with ulceration of thigh 106 106 106 311 Yes Yes Yes Yes
I70241 Atherosclerosis of native arteries of left leg with ulceration of thigh 161 161 161 Yes Yes Yes --
I70242 Atherosclerosis of native arteries of left leg with ulceration of calf 106 106 106 311 Yes Yes Yes Yes
I70242 Atherosclerosis of native arteries of left leg with ulceration of calf 161 161 161 Yes Yes Yes --
I70243 Atherosclerosis of native arteries of left leg with ulceration of ankle 106 106 106 311 Yes Yes Yes Yes
I70243 Atherosclerosis of native arteries of left leg with ulceration of ankle 161 161 161 Yes Yes Yes --

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 93 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I70244 Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot 106 106 106 311 Yes Yes Yes Yes
I70244 Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot 161 161 161 Yes Yes Yes --
I70245 Atherosclerosis of native arteries of left leg with ulceration of other part of foot 106 106 106 311 Yes Yes Yes Yes
I70245 Atherosclerosis of native arteries of left leg with ulceration of other part of foot 161 161 161 Yes Yes Yes --
I70248 Atherosclerosis of native arteries of left leg with ulceration of other part of lower leg 106 106 106 311 Yes Yes Yes Yes
I70248 Atherosclerosis of native arteries of left leg with ulceration of other part of lower leg 161 161 161 Yes Yes Yes --
I70249 Atherosclerosis of native arteries of left leg with ulceration of unspecified site 106 106 106 311 Yes Yes Yes Yes
I70249 Atherosclerosis of native arteries of left leg with ulceration of unspecified site 161 161 161 Yes Yes Yes --
I7025 Atherosclerosis of native arteries of other extremities with ulceration 106 106 106 311 Yes Yes Yes Yes
I7025 Atherosclerosis of native arteries of other extremities with ulceration 161 161 161 Yes Yes Yes --
I70261 Atherosclerosis of native arteries of extremities with gangrene, right leg 106 106 106 Yes Yes Yes No
I70262 Atherosclerosis of native arteries of extremities with gangrene, left leg 106 106 106 Yes Yes Yes No
I70263 Atherosclerosis of native arteries of extremities with gangrene, bilateral legs 106 106 106 Yes Yes Yes No
I70268 Atherosclerosis of native arteries of extremities with gangrene, other extremity 106 106 106 Yes Yes Yes No
I70269 Atherosclerosis of native arteries of extremities with gangrene, unspecified extremity 106 106 106 Yes Yes Yes No
I70291 Other atherosclerosis of native arteries of extremities, right leg 108 108 108 216 Yes Yes Yes Yes
I70292 Other atherosclerosis of native arteries of extremities, left leg 108 108 108 216 Yes Yes Yes Yes
I70293 Other atherosclerosis of native arteries of extremities, bilateral legs 108 108 108 216 Yes Yes Yes Yes
I70298 Other atherosclerosis of native arteries of extremities, other extremity 108 108 108 216 Yes Yes Yes Yes
I70299 Other atherosclerosis of native arteries of extremities, unspecified extremity 108 108 108 216 Yes Yes Yes Yes
I70301 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, right leg 108 108 108 216 Yes Yes Yes Yes
I70302 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, left leg 108 108 108 216 Yes Yes Yes Yes
I70303 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, bilateral legs 108 108 108 216 Yes Yes Yes Yes
I70308 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, other extremity 108 108 108 216 Yes Yes Yes Yes
I70309 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, unspecified 108 108 108 216 Yes Yes Yes Yes
extremity
I70311 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent 108 108 108 216 Yes Yes Yes Yes
claudication, right leg
I70312 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent 108 108 108 216 Yes Yes Yes Yes
claudication, left leg
I70313 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent 108 108 108 216 Yes Yes Yes Yes
claudication, bilateral legs
I70318 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent 108 108 108 216 Yes Yes Yes Yes
claudication, other extremity
I70319 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent 108 108 108 216 Yes Yes Yes Yes
claudication, unspecified extremity
I70321 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, right leg 108 108 108 216 Yes Yes Yes Yes
I70322 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, left leg 108 108 108 216 Yes Yes Yes Yes
I70323 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, bilateral legs 108 108 108 216 Yes Yes Yes Yes
I70328 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, other 108 108 108 216 Yes Yes Yes Yes
extremity
I70329 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, unspecified 108 108 108 216 Yes Yes Yes Yes
extremity
I70331 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of thigh 106 106 106 311 Yes Yes Yes Yes
I70331 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of thigh 161 161 161 Yes Yes Yes --
I70332 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of calf 106 106 106 311 Yes Yes Yes Yes
I70332 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of calf 161 161 161 Yes Yes Yes --
I70333 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of ankle 106 106 106 311 Yes Yes Yes Yes
I70333 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of ankle 161 161 161 Yes Yes Yes --
I70334 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of heel and 106 106 106 311 Yes Yes Yes Yes
midfoot

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 94 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I70334 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of heel and 161 161 161 Yes Yes Yes --
midfoot
I70335 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of 106 106 106 311 Yes Yes Yes Yes
foot
I70335 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of 161 161 161 Yes Yes Yes --
foot
I70338 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of 106 106 106 311 Yes Yes Yes Yes
lower leg
I70338 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of 161 161 161 Yes Yes Yes --
lower leg
I70339 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of unspecified 106 106 106 311 Yes Yes Yes Yes
site
I70339 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of unspecified 161 161 161 Yes Yes Yes --
site
I70341 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of thigh 106 106 106 311 Yes Yes Yes Yes
I70341 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of thigh 161 161 161 Yes Yes Yes --
I70342 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of calf 106 106 106 311 Yes Yes Yes Yes
I70342 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of calf 161 161 161 Yes Yes Yes --
I70343 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of ankle 106 106 106 311 Yes Yes Yes Yes
I70343 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of ankle 161 161 161 Yes Yes Yes --
I70344 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of heel and 106 106 106 311 Yes Yes Yes Yes
midfoot
I70344 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of heel and 161 161 161 Yes Yes Yes --
midfoot
I70345 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of 106 106 106 311 Yes Yes Yes Yes
foot
I70345 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of 161 161 161 Yes Yes Yes --
foot
I70348 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of 106 106 106 311 Yes Yes Yes Yes
lower leg
I70348 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of 161 161 161 Yes Yes Yes --
lower leg
I70349 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of unspecified site 106 106 106 311 Yes Yes Yes Yes

I70349 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of unspecified site 161 161 161 Yes Yes Yes --

I7035 Atherosclerosis of unspecified type of bypass graft(s) of other extremity with ulceration 106 106 106 311 Yes Yes Yes Yes
I7035 Atherosclerosis of unspecified type of bypass graft(s) of other extremity with ulceration 161 161 161 Yes Yes Yes --
I70361 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, right leg 106 106 106 Yes Yes Yes No
I70362 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, left leg 106 106 106 Yes Yes Yes No
I70363 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, bilateral legs 106 106 106 Yes Yes Yes No
I70368 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, other 106 106 106 Yes Yes Yes No
extremity
I70369 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, unspecified 106 106 106 Yes Yes Yes No
extremity
I70391 Other atherosclerosis of unspecified type of bypass graft(s) of the extremities, right leg 108 108 108 216 Yes Yes Yes Yes
I70392 Other atherosclerosis of unspecified type of bypass graft(s) of the extremities, left leg 108 108 108 216 Yes Yes Yes Yes
I70393 Other atherosclerosis of unspecified type of bypass graft(s) of the extremities, bilateral legs 108 108 108 216 Yes Yes Yes Yes
I70398 Other atherosclerosis of unspecified type of bypass graft(s) of the extremities, other extremity 108 108 108 216 Yes Yes Yes Yes
I70399 Other atherosclerosis of unspecified type of bypass graft(s) of the extremities, unspecified extremity 108 108 108 216 Yes Yes Yes Yes
I70401 Unspecified atherosclerosis of autologous vein bypass graft(s) of the extremities, right leg 108 108 108 216 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 95 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I70402 Unspecified atherosclerosis of autologous vein bypass graft(s) of the extremities, left leg 108 108 108 216 Yes Yes Yes Yes
I70403 Unspecified atherosclerosis of autologous vein bypass graft(s) of the extremities, bilateral legs 108 108 108 216 Yes Yes Yes Yes
I70408 Unspecified atherosclerosis of autologous vein bypass graft(s) of the extremities, other extremity 108 108 108 216 Yes Yes Yes Yes
I70409 Unspecified atherosclerosis of autologous vein bypass graft(s) of the extremities, unspecified 108 108 108 216 Yes Yes Yes Yes
extremity
I70411 Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, 108 108 108 216 Yes Yes Yes Yes
right leg
I70412 Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, 108 108 108 216 Yes Yes Yes Yes
left leg
I70413 Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, 108 108 108 216 Yes Yes Yes Yes
bilateral legs
I70418 Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, 108 108 108 216 Yes Yes Yes Yes
other extremity
I70419 Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, 108 108 108 216 Yes Yes Yes Yes
unspecified extremity
I70421 Atherosclerosis of autologous vein bypass graft(s) of the extremities with rest pain, right leg 108 108 108 216 Yes Yes Yes Yes
I70422 Atherosclerosis of autologous vein bypass graft(s) of the extremities with rest pain, left leg 108 108 108 216 Yes Yes Yes Yes
I70423 Atherosclerosis of autologous vein bypass graft(s) of the extremities with rest pain, bilateral legs 108 108 108 216 Yes Yes Yes Yes
I70428 Atherosclerosis of autologous vein bypass graft(s) of the extremities with rest pain, other extremity 108 108 108 216 Yes Yes Yes Yes
I70429 Atherosclerosis of autologous vein bypass graft(s) of the extremities with rest pain, unspecified 108 108 108 216 Yes Yes Yes Yes
extremity
I70431 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of thigh 106 106 106 311 Yes Yes Yes Yes
I70431 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of thigh 161 161 161 Yes Yes Yes --
I70432 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of calf 106 106 106 311 Yes Yes Yes Yes
I70432 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of calf 161 161 161 Yes Yes Yes --
I70433 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of ankle 106 106 106 311 Yes Yes Yes Yes
I70433 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of ankle 161 161 161 Yes Yes Yes --
I70434 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of heel and midfoot 106 106 106 311 Yes Yes Yes Yes
I70434 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of heel and midfoot 161 161 161 Yes Yes Yes --
I70435 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of foot 106 106 106 311 Yes Yes Yes Yes

I70435 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of foot 161 161 161 Yes Yes Yes --

I70438 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of 106 106 106 311 Yes Yes Yes Yes
lower leg
I70438 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of 161 161 161 Yes Yes Yes --
lower leg
I70439 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of unspecified site 106 106 106 311 Yes Yes Yes Yes
I70439 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of unspecified site 161 161 161 Yes Yes Yes --
I70441 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of thigh 106 106 106 311 Yes Yes Yes Yes
I70441 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of thigh 161 161 161 Yes Yes Yes --
I70442 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of calf 106 106 106 311 Yes Yes Yes Yes
I70442 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of calf 161 161 161 Yes Yes Yes --
I70443 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of ankle 106 106 106 311 Yes Yes Yes Yes
I70443 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of ankle 161 161 161 Yes Yes Yes --
I70444 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of heel and midfoot 106 106 106 311 Yes Yes Yes Yes
I70444 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of heel and midfoot 161 161 161 Yes Yes Yes --
I70445 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of foot 106 106 106 311 Yes Yes Yes Yes
I70445 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of foot 161 161 161 Yes Yes Yes --
I70448 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of lower 106 106 106 311 Yes Yes Yes Yes
leg

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 96 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I70448 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of lower 161 161 161 Yes Yes Yes --
leg
I70449 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of unspecified site 106 106 106 311 Yes Yes Yes Yes
I70449 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of unspecified site 161 161 161 Yes Yes Yes --
I7045 Atherosclerosis of autologous vein bypass graft(s) of other extremity with ulceration 106 106 106 311 Yes Yes Yes Yes
I7045 Atherosclerosis of autologous vein bypass graft(s) of other extremity with ulceration 161 161 161 Yes Yes Yes --
I70461 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, right leg 106 106 106 Yes Yes Yes No
I70462 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, left leg 106 106 106 Yes Yes Yes No
I70463 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, bilateral legs 106 106 106 Yes Yes Yes No
I70468 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, other extremity 106 106 106 Yes Yes Yes No
I70469 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, unspecified 106 106 106 Yes Yes Yes No
extremity
I70491 Other atherosclerosis of autologous vein bypass graft(s) of the extremities, right leg 108 108 108 216 Yes Yes Yes Yes
I70492 Other atherosclerosis of autologous vein bypass graft(s) of the extremities, left leg 108 108 108 216 Yes Yes Yes Yes
I70493 Other atherosclerosis of autologous vein bypass graft(s) of the extremities, bilateral legs 108 108 108 216 Yes Yes Yes Yes
I70498 Other atherosclerosis of autologous vein bypass graft(s) of the extremities, other extremity 108 108 108 216 Yes Yes Yes Yes
I70499 Other atherosclerosis of autologous vein bypass graft(s) of the extremities, unspecified extremity 108 108 108 216 Yes Yes Yes Yes
I70501 Unspecified atherosclerosis of nonautologous biological bypass graft(s) of the extremities, right leg 108 108 108 216 Yes Yes Yes Yes
I70502 Unspecified atherosclerosis of nonautologous biological bypass graft(s) of the extremities, left leg 108 108 108 216 Yes Yes Yes Yes
I70503 Unspecified atherosclerosis of nonautologous biological bypass graft(s) of the extremities, bilateral 108 108 108 216 Yes Yes Yes Yes
legs
I70508 Unspecified atherosclerosis of nonautologous biological bypass graft(s) of the extremities, other 108 108 108 216 Yes Yes Yes Yes
extremity
I70509 Unspecified atherosclerosis of nonautologous biological bypass graft(s) of the extremities, 108 108 108 216 Yes Yes Yes Yes
unspecified extremity
I70511 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent 108 108 108 216 Yes Yes Yes Yes
claudication, right leg
I70512 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent 108 108 108 216 Yes Yes Yes Yes
claudication, left leg
I70513 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent 108 108 108 216 Yes Yes Yes Yes
claudication, bilateral legs
I70518 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent 108 108 108 216 Yes Yes Yes Yes
claudication, other extremity
I70519 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent 108 108 108 216 Yes Yes Yes Yes
claudication, unspecified extremity
I70521 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with rest pain, right leg 108 108 108 216 Yes Yes Yes Yes
I70522 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with rest pain, left leg 108 108 108 216 Yes Yes Yes Yes
I70523 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with rest pain, bilateral 108 108 108 216 Yes Yes Yes Yes
legs
I70528 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with rest pain, other 108 108 108 216 Yes Yes Yes Yes
extremity
I70529 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with rest pain, 108 108 108 216 Yes Yes Yes Yes
unspecified extremity
I70531 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of thigh 106 106 106 311 Yes Yes Yes Yes
I70531 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of thigh 161 161 161 Yes Yes Yes --
I70532 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of calf 106 106 106 311 Yes Yes Yes Yes
I70532 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of calf 161 161 161 Yes Yes Yes --
I70533 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of ankle 106 106 106 311 Yes Yes Yes Yes
I70533 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of ankle 161 161 161 Yes Yes Yes --
I70534 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of heel 106 106 106 311 Yes Yes Yes Yes
and midfoot

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 97 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I70534 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of heel 161 161 161 Yes Yes Yes --
and midfoot
I70535 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other 106 106 106 311 Yes Yes Yes Yes
part of foot
I70535 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other 161 161 161 Yes Yes Yes --
part of foot
I70538 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other 106 106 106 311 Yes Yes Yes Yes
part of lower leg
I70538 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other 161 161 161 Yes Yes Yes --
part of lower leg
I70539 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of 106 106 106 311 Yes Yes Yes Yes
unspecified site
I70539 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of 161 161 161 Yes Yes Yes --
unspecified site
I70541 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of thigh 106 106 106 311 Yes Yes Yes Yes
I70541 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of thigh 161 161 161 Yes Yes Yes --
I70542 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of calf 106 106 106 311 Yes Yes Yes Yes
I70542 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of calf 161 161 161 Yes Yes Yes --
I70543 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of ankle 106 106 106 311 Yes Yes Yes Yes
I70543 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of ankle 161 161 161 Yes Yes Yes --
I70544 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of heel and 106 106 106 311 Yes Yes Yes Yes
midfoot
I70544 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of heel and 161 161 161 Yes Yes Yes --
midfoot
I70545 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other 106 106 106 311 Yes Yes Yes Yes
part of foot
I70545 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other 161 161 161 Yes Yes Yes --
part of foot
I70548 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other 106 106 106 311 Yes Yes Yes Yes
part of lower leg
I70548 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other 161 161 161 Yes Yes Yes --
part of lower leg
I70549 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of 106 106 106 311 Yes Yes Yes Yes
unspecified site
I70549 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of 161 161 161 Yes Yes Yes --
unspecified site
I7055 Atherosclerosis of nonautologous biological bypass graft(s) of other extremity with ulceration 106 106 106 311 Yes Yes Yes Yes
I7055 Atherosclerosis of nonautologous biological bypass graft(s) of other extremity with ulceration 161 161 161 Yes Yes Yes --
I70561 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, right 106 106 106 Yes Yes Yes No
leg
I70562 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, left leg 106 106 106 Yes Yes Yes No
I70563 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, 106 106 106 Yes Yes Yes No
bilateral legs
I70568 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, other 106 106 106 Yes Yes Yes No
extremity
I70569 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, 106 106 106 Yes Yes Yes No
unspecified extremity
I70591 Other atherosclerosis of nonautologous biological bypass graft(s) of the extremities, right leg 108 108 108 216 Yes Yes Yes Yes
I70592 Other atherosclerosis of nonautologous biological bypass graft(s) of the extremities, left leg 108 108 108 216 Yes Yes Yes Yes
I70593 Other atherosclerosis of nonautologous biological bypass graft(s) of the extremities, bilateral legs 108 108 108 216 Yes Yes Yes Yes
I70598 Other atherosclerosis of nonautologous biological bypass graft(s) of the extremities, other extremity 108 108 108 216 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 98 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I70599 Other atherosclerosis of nonautologous biological bypass graft(s) of the extremities, unspecified 108 108 108 216 Yes Yes Yes Yes
extremity
I70601 Unspecified atherosclerosis of nonbiological bypass graft(s) of the extremities, right leg 108 108 108 216 Yes Yes Yes Yes
I70602 Unspecified atherosclerosis of nonbiological bypass graft(s) of the extremities, left leg 108 108 108 216 Yes Yes Yes Yes
I70603 Unspecified atherosclerosis of nonbiological bypass graft(s) of the extremities, bilateral legs 108 108 108 216 Yes Yes Yes Yes
I70608 Unspecified atherosclerosis of nonbiological bypass graft(s) of the extremities, other extremity 108 108 108 216 Yes Yes Yes Yes
I70609 Unspecified atherosclerosis of nonbiological bypass graft(s) of the extremities, unspecified extremity 108 108 108 216 Yes Yes Yes Yes
I70611 Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, 108 108 108 216 Yes Yes Yes Yes
right leg
I70612 Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, left 108 108 108 216 Yes Yes Yes Yes
leg
I70613 Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, 108 108 108 216 Yes Yes Yes Yes
bilateral legs
I70618 Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, 108 108 108 216 Yes Yes Yes Yes
other extremity
I70619 Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, 108 108 108 216 Yes Yes Yes Yes
unspecified extremity
I70621 Atherosclerosis of nonbiological bypass graft(s) of the extremities with rest pain, right leg 108 108 108 216 Yes Yes Yes Yes
I70622 Atherosclerosis of nonbiological bypass graft(s) of the extremities with rest pain, left leg 108 108 108 216 Yes Yes Yes Yes
I70623 Atherosclerosis of nonbiological bypass graft(s) of the extremities with rest pain, bilateral legs 108 108 108 216 Yes Yes Yes Yes
I70628 Atherosclerosis of nonbiological bypass graft(s) of the extremities with rest pain, other extremity 108 108 108 216 Yes Yes Yes Yes
I70629 Atherosclerosis of nonbiological bypass graft(s) of the extremities with rest pain, unspecified 108 108 108 216 Yes Yes Yes Yes
extremity
I70631 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of thigh 106 106 106 311 Yes Yes Yes Yes
I70631 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of thigh 161 161 161 Yes Yes Yes --
I70632 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of calf 106 106 106 311 Yes Yes Yes Yes
I70632 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of calf 161 161 161 Yes Yes Yes --
I70633 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of ankle 106 106 106 311 Yes Yes Yes Yes
I70633 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of ankle 161 161 161 Yes Yes Yes --
I70634 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of heel and midfoot 106 106 106 311 Yes Yes Yes Yes
I70634 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of heel and midfoot 161 161 161 Yes Yes Yes --
I70635 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of foot 106 106 106 311 Yes Yes Yes Yes
I70635 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of foot 161 161 161 Yes Yes Yes --
I70638 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of lower 106 106 106 311 Yes Yes Yes Yes
leg
I70638 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of lower 161 161 161 Yes Yes Yes --
leg
I70639 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of unspecified site 106 106 106 311 Yes Yes Yes Yes
I70639 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of unspecified site 161 161 161 Yes Yes Yes --
I70641 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of thigh 106 106 106 311 Yes Yes Yes Yes
I70641 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of thigh 161 161 161 Yes Yes Yes --
I70642 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of calf 106 106 106 311 Yes Yes Yes Yes
I70642 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of calf 161 161 161 Yes Yes Yes --
I70643 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of ankle 106 106 106 311 Yes Yes Yes Yes
I70643 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of ankle 161 161 161 Yes Yes Yes --
I70644 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of heel and midfoot 106 106 106 311 Yes Yes Yes Yes
I70644 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of heel and midfoot 161 161 161 Yes Yes Yes --
I70645 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of other part of foot 106 106 106 311 Yes Yes Yes Yes
I70645 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of other part of foot 161 161 161 Yes Yes Yes --
I70648 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of other part of lower 106 106 106 311 Yes Yes Yes Yes
leg

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 99 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I70648 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of other part of lower 161 161 161 Yes Yes Yes --
leg
I70649 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of unspecified site 106 106 106 311 Yes Yes Yes Yes
I70649 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of unspecified site 161 161 161 Yes Yes Yes --
I7065 Atherosclerosis of nonbiological bypass graft(s) of other extremity with ulceration 106 106 106 311 Yes Yes Yes Yes
I7065 Atherosclerosis of nonbiological bypass graft(s) of other extremity with ulceration 161 161 161 Yes Yes Yes --
I70661 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, right leg 106 106 106 Yes Yes Yes No
I70662 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, left leg 106 106 106 Yes Yes Yes No
I70663 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, bilateral legs 106 106 106 Yes Yes Yes No
I70668 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, other extremity 106 106 106 Yes Yes Yes No
I70669 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, unspecified 106 106 106 Yes Yes Yes No
extremity
I70691 Other atherosclerosis of nonbiological bypass graft(s) of the extremities, right leg 108 108 108 216 Yes Yes Yes Yes
I70692 Other atherosclerosis of nonbiological bypass graft(s) of the extremities, left leg 108 108 108 216 Yes Yes Yes Yes
I70693 Other atherosclerosis of nonbiological bypass graft(s) of the extremities, bilateral legs 108 108 108 216 Yes Yes Yes Yes
I70698 Other atherosclerosis of nonbiological bypass graft(s) of the extremities, other extremity 108 108 108 216 Yes Yes Yes Yes
I70699 Other atherosclerosis of nonbiological bypass graft(s) of the extremities, unspecified extremity 108 108 108 216 Yes Yes Yes Yes
I70701 Unspecified atherosclerosis of other type of bypass graft(s) of the extremities, right leg 108 108 108 216 Yes Yes Yes Yes
I70702 Unspecified atherosclerosis of other type of bypass graft(s) of the extremities, left leg 108 108 108 216 Yes Yes Yes Yes
I70703 Unspecified atherosclerosis of other type of bypass graft(s) of the extremities, bilateral legs 108 108 108 216 Yes Yes Yes Yes
I70708 Unspecified atherosclerosis of other type of bypass graft(s) of the extremities, other extremity 108 108 108 216 Yes Yes Yes Yes
I70709 Unspecified atherosclerosis of other type of bypass graft(s) of the extremities, unspecified extremity 108 108 108 216 Yes Yes Yes Yes
I70711 Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, 108 108 108 216 Yes Yes Yes Yes
right leg
I70712 Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, left 108 108 108 216 Yes Yes Yes Yes
leg
I70713 Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, 108 108 108 216 Yes Yes Yes Yes
bilateral legs
I70718 Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, 108 108 108 216 Yes Yes Yes Yes
other extremity
I70719 Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, 108 108 108 216 Yes Yes Yes Yes
unspecified extremity
I70721 Atherosclerosis of other type of bypass graft(s) of the extremities with rest pain, right leg 108 108 108 216 Yes Yes Yes Yes
I70722 Atherosclerosis of other type of bypass graft(s) of the extremities with rest pain, left leg 108 108 108 216 Yes Yes Yes Yes
I70723 Atherosclerosis of other type of bypass graft(s) of the extremities with rest pain, bilateral legs 108 108 108 216 Yes Yes Yes Yes
I70728 Atherosclerosis of other type of bypass graft(s) of the extremities with rest pain, other extremity 108 108 108 216 Yes Yes Yes Yes
I70729 Atherosclerosis of other type of bypass graft(s) of the extremities with rest pain, unspecified 108 108 108 216 Yes Yes Yes Yes
extremity
I70731 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of thigh 106 106 106 311 Yes Yes Yes Yes
I70731 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of thigh 161 161 161 Yes Yes Yes --
I70732 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of calf 106 106 106 311 Yes Yes Yes Yes
I70732 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of calf 161 161 161 Yes Yes Yes --
I70733 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of ankle 106 106 106 311 Yes Yes Yes Yes
I70733 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of ankle 161 161 161 Yes Yes Yes --
I70734 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of heel and midfoot 106 106 106 311 Yes Yes Yes Yes
I70734 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of heel and midfoot 161 161 161 Yes Yes Yes --
I70735 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of other part of foot 106 106 106 311 Yes Yes Yes Yes
I70735 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of other part of foot 161 161 161 Yes Yes Yes --
I70738 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of other part of lower 106 106 106 311 Yes Yes Yes Yes
leg

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 100 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I70738 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of other part of lower 161 161 161 Yes Yes Yes --
leg
I70739 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of unspecified site 106 106 106 311 Yes Yes Yes Yes
I70739 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of unspecified site 161 161 161 Yes Yes Yes --
I70741 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of thigh 106 106 106 311 Yes Yes Yes Yes
I70741 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of thigh 161 161 161 Yes Yes Yes --
I70742 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of calf 106 106 106 311 Yes Yes Yes Yes
I70742 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of calf 161 161 161 Yes Yes Yes --
I70743 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of ankle 106 106 106 311 Yes Yes Yes Yes
I70743 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of ankle 161 161 161 Yes Yes Yes --
I70744 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of heel and midfoot 106 106 106 311 Yes Yes Yes Yes
I70744 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of heel and midfoot 161 161 161 Yes Yes Yes --
I70745 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of other part of foot 106 106 106 311 Yes Yes Yes Yes
I70745 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of other part of foot 161 161 161 Yes Yes Yes --
I70748 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of other part of lower 106 106 106 311 Yes Yes Yes Yes
leg
I70748 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of other part of lower 161 161 161 Yes Yes Yes --
leg
I70749 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of unspecified site 106 106 106 311 Yes Yes Yes Yes
I70749 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of unspecified site 161 161 161 Yes Yes Yes --
I7075 Atherosclerosis of other type of bypass graft(s) of other extremity with ulceration 106 106 106 311 Yes Yes Yes Yes
I7075 Atherosclerosis of other type of bypass graft(s) of other extremity with ulceration 161 161 161 Yes Yes Yes --
I70761 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, right leg 106 106 106 Yes Yes Yes No
I70762 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, left leg 106 106 106 Yes Yes Yes No
I70763 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, bilateral legs 106 106 106 Yes Yes Yes No
I70768 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, other extremity 106 106 106 Yes Yes Yes No
I70769 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, unspecified 106 106 106 Yes Yes Yes No
extremity
I70791 Other atherosclerosis of other type of bypass graft(s) of the extremities, right leg 108 108 108 216 Yes Yes Yes Yes
I70792 Other atherosclerosis of other type of bypass graft(s) of the extremities, left leg 108 108 108 216 Yes Yes Yes Yes
I70793 Other atherosclerosis of other type of bypass graft(s) of the extremities, bilateral legs 108 108 108 216 Yes Yes Yes Yes
I70798 Other atherosclerosis of other type of bypass graft(s) of the extremities, other extremity 108 108 108 216 Yes Yes Yes Yes
I70799 Other atherosclerosis of other type of bypass graft(s) of the extremities, unspecified extremity 108 108 108 216 Yes Yes Yes Yes
I7092 Chronic total occlusion of artery of the extremities 108 108 108 216 Yes Yes Yes Yes
I7100 Dissection of unspecified site of aorta 107 107 107 Yes Yes Yes No
I7101 Dissection of thoracic aorta 107 107 107 Yes Yes Yes No
I7102 Dissection of abdominal aorta 107 107 107 Yes Yes Yes No
I7103 Dissection of thoracoabdominal aorta 107 107 107 Yes Yes Yes No
I711 Thoracic aortic aneurysm, ruptured 107 107 107 Yes Yes Yes No
I712 Thoracic aortic aneurysm, without rupture 108 108 108 Yes Yes Yes No
I713 Abdominal aortic aneurysm, ruptured 107 107 107 Yes Yes Yes No
I714 Abdominal aortic aneurysm, without rupture 108 108 108 Yes Yes Yes No
I715 Thoracoabdominal aortic aneurysm, ruptured 107 107 107 Yes Yes Yes No
I716 Thoracoabdominal aortic aneurysm, without rupture 108 108 108 Yes Yes Yes No
I718 Aortic aneurysm of unspecified site, ruptured 107 107 107 Yes Yes Yes No
I719 Aortic aneurysm of unspecified site, without rupture 108 108 108 Yes Yes Yes No
I720 Aneurysm of carotid artery 108 108 108 Yes Yes Yes No
I721 Aneurysm of artery of upper extremity 108 108 108 Yes Yes Yes No
I722 Aneurysm of renal artery 108 108 108 Yes Yes Yes No
I723 Aneurysm of iliac artery 108 108 108 Yes Yes Yes No
I724 Aneurysm of artery of lower extremity 108 108 108 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 101 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I725 Aneurysm of other precerebral arteries 108 108 108 Yes Yes Yes No
I726 Aneurysm of vertebral artery 108 108 108 Yes Yes Yes No
I728 Aneurysm of other specified arteries 108 108 108 Yes Yes Yes No
I729 Aneurysm of unspecified site 108 108 108 Yes Yes Yes No
I7301 Raynaud's syndrome with gangrene 106 106 106 Yes Yes Yes No
I731 Thromboangiitis obliterans [Buerger's disease] 108 108 108 216 Yes Yes Yes Yes
I7381 Erythromelalgia 108 108 108 216 Yes Yes Yes Yes
I7389 Other specified peripheral vascular diseases 108 108 108 216 Yes Yes Yes Yes
I739 Peripheral vascular disease, unspecified 108 108 108 216 Yes Yes Yes Yes
I7401 Saddle embolus of abdominal aorta 107 107 107 Yes Yes Yes No
I7409 Other arterial embolism and thrombosis of abdominal aorta 107 107 107 Yes Yes Yes No
I7410 Embolism and thrombosis of unspecified parts of aorta 107 107 107 Yes Yes Yes No
I7411 Embolism and thrombosis of thoracic aorta 107 107 107 Yes Yes Yes No
I7419 Embolism and thrombosis of other parts of aorta 107 107 107 Yes Yes Yes No
I742 Embolism and thrombosis of arteries of the upper extremities 107 107 107 Yes Yes Yes No
I743 Embolism and thrombosis of arteries of the lower extremities 107 107 107 Yes Yes Yes No
I744 Embolism and thrombosis of arteries of extremities, unspecified 107 107 107 Yes Yes Yes No
I745 Embolism and thrombosis of iliac artery 107 107 107 Yes Yes Yes No
I748 Embolism and thrombosis of other arteries 107 107 107 Yes Yes Yes No
I749 Embolism and thrombosis of unspecified artery 107 107 107 Yes Yes Yes No
I75011 Atheroembolism of right upper extremity 107 107 107 Yes Yes Yes No
I75012 Atheroembolism of left upper extremity 107 107 107 Yes Yes Yes No
I75013 Atheroembolism of bilateral upper extremities 107 107 107 Yes Yes Yes No
I75019 Atheroembolism of unspecified upper extremity 107 107 107 Yes Yes Yes No
I75021 Atheroembolism of right lower extremity 107 107 107 Yes Yes Yes No
I75022 Atheroembolism of left lower extremity 107 107 107 Yes Yes Yes No
I75023 Atheroembolism of bilateral lower extremities 107 107 107 Yes Yes Yes No
I75029 Atheroembolism of unspecified lower extremity 107 107 107 Yes Yes Yes No
I7581 Atheroembolism of kidney 107 107 107 Yes Yes Yes No
I7589 Atheroembolism of other site 107 107 107 Yes Yes Yes No
I76 Septic arterial embolism 107 107 107 Yes Yes Yes No
I770 Arteriovenous fistula, acquired 108 108 108 Yes Yes Yes No
I771 Stricture of artery 108 108 108 Yes Yes Yes No
I772 Rupture of artery 108 108 108 Yes Yes Yes No
I773 Arterial fibromuscular dysplasia 108 108 108 Yes Yes Yes No
I774 Celiac artery compression syndrome 108 108 108 Yes Yes Yes No
I775 Necrosis of artery 108 108 108 Yes Yes Yes No
I776 Arteritis, unspecified 108 108 108 Yes Yes Yes No
I7770 Dissection of unspecified artery 107 107 107 Yes Yes Yes No
I7771 Dissection of carotid artery 107 107 107 Yes Yes Yes No
I7772 Dissection of iliac artery 107 107 107 Yes Yes Yes No
I7773 Dissection of renal artery 107 107 107 Yes Yes Yes No
I7774 Dissection of vertebral artery 107 107 107 Yes Yes Yes No
I7775 Dissection of other precerebral arteries 107 107 107 Yes Yes Yes No
I7776 Dissection of artery of upper extremity 107 107 107 Yes Yes Yes No
I7777 Dissection of artery of lower extremity 107 107 107 Yes Yes Yes No
I7779 Dissection of other specified artery 107 107 107 Yes Yes Yes No
I77810 Thoracic aortic ectasia 108 108 108 Yes Yes Yes No
I77811 Abdominal aortic ectasia 108 108 108 Yes Yes Yes No
I77812 Thoracoabdominal aortic ectasia 108 108 108 Yes Yes Yes No
I77819 Aortic ectasia, unspecified site 108 108 108 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 102 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I7789 Other specified disorders of arteries and arterioles 108 108 108 Yes Yes Yes No
I779 Disorder of arteries and arterioles, unspecified 108 108 108 Yes Yes Yes No
I780 Hereditary hemorrhagic telangiectasia 108 108 108 Yes Yes Yes No
I790 Aneurysm of aorta in diseases classified elsewhere 108 108 108 Yes Yes Yes No
I791 Aortitis in diseases classified elsewhere 108 108 108 216 Yes Yes Yes Yes
I798 Other disorders of arteries, arterioles and capillaries in diseases classified elsewhere 108 108 108 216 Yes Yes Yes Yes
I8010 Phlebitis and thrombophlebitis of unspecified femoral vein 108 108 108 215 Yes Yes Yes Yes
I8011 Phlebitis and thrombophlebitis of right femoral vein 108 108 108 215 Yes Yes Yes Yes
I8012 Phlebitis and thrombophlebitis of left femoral vein 108 108 108 215 Yes Yes Yes Yes
I8013 Phlebitis and thrombophlebitis of femoral vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I80201 Phlebitis and thrombophlebitis of unspecified deep vessels of right lower extremity 108 108 108 215 Yes Yes Yes Yes
I80202 Phlebitis and thrombophlebitis of unspecified deep vessels of left lower extremity 108 108 108 215 Yes Yes Yes Yes
I80203 Phlebitis and thrombophlebitis of unspecified deep vessels of lower extremities, bilateral 108 108 108 215 Yes Yes Yes Yes
I80209 Phlebitis and thrombophlebitis of unspecified deep vessels of unspecified lower extremity 108 108 108 215 Yes Yes Yes Yes
I80211 Phlebitis and thrombophlebitis of right iliac vein 108 108 108 215 Yes Yes Yes Yes
I80212 Phlebitis and thrombophlebitis of left iliac vein 108 108 108 215 Yes Yes Yes Yes
I80213 Phlebitis and thrombophlebitis of iliac vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I80219 Phlebitis and thrombophlebitis of unspecified iliac vein 108 108 108 215 Yes Yes Yes Yes
I80221 Phlebitis and thrombophlebitis of right popliteal vein 108 108 108 215 Yes Yes Yes Yes
I80222 Phlebitis and thrombophlebitis of left popliteal vein 108 108 108 215 Yes Yes Yes Yes
I80223 Phlebitis and thrombophlebitis of popliteal vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I80229 Phlebitis and thrombophlebitis of unspecified popliteal vein 108 108 108 215 Yes Yes Yes Yes
I80231 Phlebitis and thrombophlebitis of right tibial vein 108 108 108 215 Yes Yes Yes Yes
I80232 Phlebitis and thrombophlebitis of left tibial vein 108 108 108 215 Yes Yes Yes Yes
I80233 Phlebitis and thrombophlebitis of tibial vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I80239 Phlebitis and thrombophlebitis of unspecified tibial vein 108 108 108 215 Yes Yes Yes Yes
I80241 Phlebitis and thrombophlebitis of right peroneal vein 108 108 108 215 Yes Yes Yes Yes
I80242 Phlebitis and thrombophlebitis of left peroneal vein 108 108 108 215 Yes Yes Yes Yes
I80243 Phlebitis and thrombophlebitis of peroneal vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I80249 Phlebitis and thrombophlebitis of unspecified peroneal vein 108 108 108 215 Yes Yes Yes Yes
I80251 Phlebitis and thrombophlebitis of right calf muscular vein 108 108 108 215 Yes Yes Yes Yes
I80252 Phlebitis and thrombophlebitis of left calf muscular vein 108 108 108 215 Yes Yes Yes Yes
I80253 Phlebitis and thrombophlebitis of calf muscular vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I80259 Phlebitis and thrombophlebitis of unspecified calf muscular vein 108 108 108 215 Yes Yes Yes Yes
I80291 Phlebitis and thrombophlebitis of other deep vessels of right lower extremity 108 108 108 215 Yes Yes Yes Yes
I80292 Phlebitis and thrombophlebitis of other deep vessels of left lower extremity 108 108 108 215 Yes Yes Yes Yes
I80293 Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateral 108 108 108 215 Yes Yes Yes Yes
I80299 Phlebitis and thrombophlebitis of other deep vessels of unspecified lower extremity 108 108 108 215 Yes Yes Yes Yes
I820 Budd-Chiari syndrome 108 108 108 215 Yes Yes Yes Yes
I82210 Acute embolism and thrombosis of superior vena cava 108 108 108 215 Yes Yes Yes Yes
I82211 Chronic embolism and thrombosis of superior vena cava 108 108 108 215 Yes Yes Yes Yes
I82220 Acute embolism and thrombosis of inferior vena cava 108 108 108 215 Yes Yes Yes Yes
I82221 Chronic embolism and thrombosis of inferior vena cava 108 108 108 215 Yes Yes Yes Yes
I82290 Acute embolism and thrombosis of other thoracic veins 108 108 108 215 Yes Yes Yes Yes
I82291 Chronic embolism and thrombosis of other thoracic veins 108 108 108 215 Yes Yes Yes Yes
I823 Embolism and thrombosis of renal vein 108 108 108 215 Yes Yes Yes Yes
I82401 Acute embolism and thrombosis of unspecified deep veins of right lower extremity 108 108 108 215 Yes Yes Yes Yes
I82402 Acute embolism and thrombosis of unspecified deep veins of left lower extremity 108 108 108 215 Yes Yes Yes Yes
I82403 Acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateral 108 108 108 215 Yes Yes Yes Yes
I82409 Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity 108 108 108 215 Yes Yes Yes Yes
I82411 Acute embolism and thrombosis of right femoral vein 108 108 108 215 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 103 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I82412 Acute embolism and thrombosis of left femoral vein 108 108 108 215 Yes Yes Yes Yes
I82413 Acute embolism and thrombosis of femoral vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I82419 Acute embolism and thrombosis of unspecified femoral vein 108 108 108 215 Yes Yes Yes Yes
I82421 Acute embolism and thrombosis of right iliac vein 108 108 108 215 Yes Yes Yes Yes
I82422 Acute embolism and thrombosis of left iliac vein 108 108 108 215 Yes Yes Yes Yes
I82423 Acute embolism and thrombosis of iliac vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I82429 Acute embolism and thrombosis of unspecified iliac vein 108 108 108 215 Yes Yes Yes Yes
I82431 Acute embolism and thrombosis of right popliteal vein 108 108 108 215 Yes Yes Yes Yes
I82432 Acute embolism and thrombosis of left popliteal vein 108 108 108 215 Yes Yes Yes Yes
I82433 Acute embolism and thrombosis of popliteal vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I82439 Acute embolism and thrombosis of unspecified popliteal vein 108 108 108 215 Yes Yes Yes Yes
I82441 Acute embolism and thrombosis of right tibial vein 108 108 108 215 Yes Yes Yes Yes
I82442 Acute embolism and thrombosis of left tibial vein 108 108 108 215 Yes Yes Yes Yes
I82443 Acute embolism and thrombosis of tibial vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I82449 Acute embolism and thrombosis of unspecified tibial vein 108 108 108 215 Yes Yes Yes Yes
I82451 Acute embolism and thrombosis of right peroneal vein 108 108 108 215 Yes Yes Yes Yes
I82452 Acute embolism and thrombosis of left peroneal vein 108 108 108 215 Yes Yes Yes Yes
I82453 Acute embolism and thrombosis of peroneal vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I82459 Acute embolism and thrombosis of unspecified peroneal vein 108 108 108 215 Yes Yes Yes Yes
I82461 Acute embolism and thrombosis of right calf muscular vein 108 108 108 215 Yes Yes Yes Yes
I82462 Acute embolism and thrombosis of left calf muscular vein 108 108 108 215 Yes Yes Yes Yes
I82463 Acute embolism and thrombosis of calf muscular vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I82469 Acute embolism and thrombosis of unspecified calf muscular vein 108 108 108 215 Yes Yes Yes Yes
I82491 Acute embolism and thrombosis of other specified deep vein of right lower extremity 108 108 108 215 Yes Yes Yes Yes
I82492 Acute embolism and thrombosis of other specified deep vein of left lower extremity 108 108 108 215 Yes Yes Yes Yes
I82493 Acute embolism and thrombosis of other specified deep vein of lower extremity, bilateral 108 108 108 215 Yes Yes Yes Yes
I82499 Acute embolism and thrombosis of other specified deep vein of unspecified lower extremity 108 108 108 215 Yes Yes Yes Yes
I824Y1 Acute embolism and thrombosis of unspecified deep veins of right proximal lower extremity 108 108 108 215 Yes Yes Yes Yes
I824Y2 Acute embolism and thrombosis of unspecified deep veins of left proximal lower extremity 108 108 108 215 Yes Yes Yes Yes
I824Y3 Acute embolism and thrombosis of unspecified deep veins of proximal lower extremity, bilateral 108 108 108 215 Yes Yes Yes Yes
I824Y9 Acute embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity 108 108 108 215 Yes Yes Yes Yes
I824Z1 Acute embolism and thrombosis of unspecified deep veins of right distal lower extremity 108 108 108 215 Yes Yes Yes Yes
I824Z2 Acute embolism and thrombosis of unspecified deep veins of left distal lower extremity 108 108 108 215 Yes Yes Yes Yes
I824Z3 Acute embolism and thrombosis of unspecified deep veins of distal lower extremity, bilateral 108 108 108 215 Yes Yes Yes Yes
I824Z9 Acute embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity 108 108 108 215 Yes Yes Yes Yes
I82501 Chronic embolism and thrombosis of unspecified deep veins of right lower extremity 108 108 108 215 Yes Yes Yes Yes
I82502 Chronic embolism and thrombosis of unspecified deep veins of left lower extremity 108 108 108 215 Yes Yes Yes Yes
I82503 Chronic embolism and thrombosis of unspecified deep veins of lower extremity, bilateral 108 108 108 215 Yes Yes Yes Yes
I82509 Chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity 108 108 108 215 Yes Yes Yes Yes
I82511 Chronic embolism and thrombosis of right femoral vein 108 108 108 215 Yes Yes Yes Yes
I82512 Chronic embolism and thrombosis of left femoral vein 108 108 108 215 Yes Yes Yes Yes
I82513 Chronic embolism and thrombosis of femoral vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I82519 Chronic embolism and thrombosis of unspecified femoral vein 108 108 108 215 Yes Yes Yes Yes
I82521 Chronic embolism and thrombosis of right iliac vein 108 108 108 215 Yes Yes Yes Yes
I82522 Chronic embolism and thrombosis of left iliac vein 108 108 108 215 Yes Yes Yes Yes
I82523 Chronic embolism and thrombosis of iliac vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I82529 Chronic embolism and thrombosis of unspecified iliac vein 108 108 108 215 Yes Yes Yes Yes
I82531 Chronic embolism and thrombosis of right popliteal vein 108 108 108 215 Yes Yes Yes Yes
I82532 Chronic embolism and thrombosis of left popliteal vein 108 108 108 215 Yes Yes Yes Yes
I82533 Chronic embolism and thrombosis of popliteal vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I82539 Chronic embolism and thrombosis of unspecified popliteal vein 108 108 108 215 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 104 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I82541 Chronic embolism and thrombosis of right tibial vein 108 108 108 215 Yes Yes Yes Yes
I82542 Chronic embolism and thrombosis of left tibial vein 108 108 108 215 Yes Yes Yes Yes
I82543 Chronic embolism and thrombosis of tibial vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I82549 Chronic embolism and thrombosis of unspecified tibial vein 108 108 108 215 Yes Yes Yes Yes
I82551 Chronic embolism and thrombosis of right peroneal vein 108 108 108 215 Yes Yes Yes Yes
I82552 Chronic embolism and thrombosis of left peroneal vein 108 108 108 215 Yes Yes Yes Yes
I82553 Chronic embolism and thrombosis of peroneal vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I82559 Chronic embolism and thrombosis of unspecified peroneal vein 108 108 108 215 Yes Yes Yes Yes
I82561 Chronic embolism and thrombosis of right calf muscular vein 108 108 108 215 Yes Yes Yes Yes
I82562 Chronic embolism and thrombosis of left calf muscular vein 108 108 108 215 Yes Yes Yes Yes
I82563 Chronic embolism and thrombosis of calf muscular vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I82569 Chronic embolism and thrombosis of unspecified calf muscular vein 108 108 108 215 Yes Yes Yes Yes
I82591 Chronic embolism and thrombosis of other specified deep vein of right lower extremity 108 108 108 215 Yes Yes Yes Yes
I82592 Chronic embolism and thrombosis of other specified deep vein of left lower extremity 108 108 108 215 Yes Yes Yes Yes
I82593 Chronic embolism and thrombosis of other specified deep vein of lower extremity, bilateral 108 108 108 215 Yes Yes Yes Yes
I82599 Chronic embolism and thrombosis of other specified deep vein of unspecified lower extremity 108 108 108 215 Yes Yes Yes Yes
I825Y1 Chronic embolism and thrombosis of unspecified deep veins of right proximal lower extremity 108 108 108 215 Yes Yes Yes Yes
I825Y2 Chronic embolism and thrombosis of unspecified deep veins of left proximal lower extremity 108 108 108 215 Yes Yes Yes Yes
I825Y3 Chronic embolism and thrombosis of unspecified deep veins of proximal lower extremity, bilateral 108 108 108 215 Yes Yes Yes Yes
I825Y9 Chronic embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity 108 108 108 215 Yes Yes Yes Yes

I825Z1 Chronic embolism and thrombosis of unspecified deep veins of right distal lower extremity 108 108 108 215 Yes Yes Yes Yes
I825Z2 Chronic embolism and thrombosis of unspecified deep veins of left distal lower extremity 108 108 108 215 Yes Yes Yes Yes
I825Z3 Chronic embolism and thrombosis of unspecified deep veins of distal lower extremity, bilateral 108 108 108 215 Yes Yes Yes Yes
I825Z9 Chronic embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity 108 108 108 215 Yes Yes Yes Yes
I82621 Acute embolism and thrombosis of deep veins of right upper extremity 108 108 108 215 Yes Yes Yes Yes
I82622 Acute embolism and thrombosis of deep veins of left upper extremity 108 108 108 215 Yes Yes Yes Yes
I82623 Acute embolism and thrombosis of deep veins of upper extremity, bilateral 108 108 108 215 Yes Yes Yes Yes
I82629 Acute embolism and thrombosis of deep veins of unspecified upper extremity 108 108 108 215 Yes Yes Yes Yes
I82721 Chronic embolism and thrombosis of deep veins of right upper extremity 108 108 108 215 Yes Yes Yes Yes
I82722 Chronic embolism and thrombosis of deep veins of left upper extremity 108 108 108 215 Yes Yes Yes Yes
I82723 Chronic embolism and thrombosis of deep veins of upper extremity, bilateral 108 108 108 215 Yes Yes Yes Yes
I82729 Chronic embolism and thrombosis of deep veins of unspecified upper extremity 108 108 108 215 Yes Yes Yes Yes
I82A11 Acute embolism and thrombosis of right axillary vein 108 108 108 215 Yes Yes Yes Yes
I82A12 Acute embolism and thrombosis of left axillary vein 108 108 108 215 Yes Yes Yes Yes
I82A13 Acute embolism and thrombosis of axillary vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I82A19 Acute embolism and thrombosis of unspecified axillary vein 108 108 108 215 Yes Yes Yes Yes
I82A21 Chronic embolism and thrombosis of right axillary vein 108 108 108 215 Yes Yes Yes Yes
I82A22 Chronic embolism and thrombosis of left axillary vein 108 108 108 215 Yes Yes Yes Yes
I82A23 Chronic embolism and thrombosis of axillary vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I82A29 Chronic embolism and thrombosis of unspecified axillary vein 108 108 108 215 Yes Yes Yes Yes
I82B11 Acute embolism and thrombosis of right subclavian vein 108 108 108 215 Yes Yes Yes Yes
I82B12 Acute embolism and thrombosis of left subclavian vein 108 108 108 215 Yes Yes Yes Yes
I82B13 Acute embolism and thrombosis of subclavian vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I82B19 Acute embolism and thrombosis of unspecified subclavian vein 108 108 108 215 Yes Yes Yes Yes
I82B21 Chronic embolism and thrombosis of right subclavian vein 108 108 108 215 Yes Yes Yes Yes
I82B22 Chronic embolism and thrombosis of left subclavian vein 108 108 108 215 Yes Yes Yes Yes
I82B23 Chronic embolism and thrombosis of subclavian vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I82B29 Chronic embolism and thrombosis of unspecified subclavian vein 108 108 108 215 Yes Yes Yes Yes
I82C11 Acute embolism and thrombosis of right internal jugular vein 108 108 108 215 Yes Yes Yes Yes
I82C12 Acute embolism and thrombosis of left internal jugular vein 108 108 108 215 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 105 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I82C13 Acute embolism and thrombosis of internal jugular vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I82C19 Acute embolism and thrombosis of unspecified internal jugular vein 108 108 108 215 Yes Yes Yes Yes
I82C21 Chronic embolism and thrombosis of right internal jugular vein 108 108 108 215 Yes Yes Yes Yes
I82C22 Chronic embolism and thrombosis of left internal jugular vein 108 108 108 215 Yes Yes Yes Yes
I82C23 Chronic embolism and thrombosis of internal jugular vein, bilateral 108 108 108 215 Yes Yes Yes Yes
I82C29 Chronic embolism and thrombosis of unspecified internal jugular vein 108 108 108 215 Yes Yes Yes Yes
I83001 Varicose veins of unspecified lower extremity with ulcer of thigh 107 107 107 Yes Yes Yes No
I83002 Varicose veins of unspecified lower extremity with ulcer of calf 107 107 107 Yes Yes Yes No
I83003 Varicose veins of unspecified lower extremity with ulcer of ankle 107 107 107 Yes Yes Yes No
I83004 Varicose veins of unspecified lower extremity with ulcer of heel and midfoot 107 107 107 Yes Yes Yes No
I83005 Varicose veins of unspecified lower extremity with ulcer other part of foot 107 107 107 Yes Yes Yes No
I83008 Varicose veins of unspecified lower extremity with ulcer other part of lower leg 107 107 107 Yes Yes Yes No
I83009 Varicose veins of unspecified lower extremity with ulcer of unspecified site 107 107 107 Yes Yes Yes No
I83011 Varicose veins of right lower extremity with ulcer of thigh 107 107 107 Yes Yes Yes No
I83012 Varicose veins of right lower extremity with ulcer of calf 107 107 107 Yes Yes Yes No
I83013 Varicose veins of right lower extremity with ulcer of ankle 107 107 107 Yes Yes Yes No
I83014 Varicose veins of right lower extremity with ulcer of heel and midfoot 107 107 107 Yes Yes Yes No
I83015 Varicose veins of right lower extremity with ulcer other part of foot 107 107 107 Yes Yes Yes No
I83018 Varicose veins of right lower extremity with ulcer other part of lower leg 107 107 107 Yes Yes Yes No
I83019 Varicose veins of right lower extremity with ulcer of unspecified site 107 107 107 Yes Yes Yes No
I83021 Varicose veins of left lower extremity with ulcer of thigh 107 107 107 Yes Yes Yes No
I83022 Varicose veins of left lower extremity with ulcer of calf 107 107 107 Yes Yes Yes No
I83023 Varicose veins of left lower extremity with ulcer of ankle 107 107 107 Yes Yes Yes No
I83024 Varicose veins of left lower extremity with ulcer of heel and midfoot 107 107 107 Yes Yes Yes No
I83025 Varicose veins of left lower extremity with ulcer other part of foot 107 107 107 Yes Yes Yes No
I83028 Varicose veins of left lower extremity with ulcer other part of lower leg 107 107 107 Yes Yes Yes No
I83029 Varicose veins of left lower extremity with ulcer of unspecified site 107 107 107 Yes Yes Yes No
I83201 Varicose veins of unspecified lower extremity with both ulcer of thigh and inflammation 107 107 107 Yes Yes Yes No
I83202 Varicose veins of unspecified lower extremity with both ulcer of calf and inflammation 107 107 107 Yes Yes Yes No
I83203 Varicose veins of unspecified lower extremity with both ulcer of ankle and inflammation 107 107 107 Yes Yes Yes No
I83204 Varicose veins of unspecified lower extremity with both ulcer of heel and midfoot and inflammation 107 107 107 Yes Yes Yes No
I83205 Varicose veins of unspecified lower extremity with both ulcer other part of foot and inflammation 107 107 107 Yes Yes Yes No
I83208 Varicose veins of unspecified lower extremity with both ulcer of other part of lower extremity and 107 107 107 Yes Yes Yes No
inflammation
I83209 Varicose veins of unspecified lower extremity with both ulcer of unspecified site and inflammation 107 107 107 Yes Yes Yes No
I83211 Varicose veins of right lower extremity with both ulcer of thigh and inflammation 107 107 107 Yes Yes Yes No
I83212 Varicose veins of right lower extremity with both ulcer of calf and inflammation 107 107 107 Yes Yes Yes No
I83213 Varicose veins of right lower extremity with both ulcer of ankle and inflammation 107 107 107 Yes Yes Yes No
I83214 Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation 107 107 107 Yes Yes Yes No
I83215 Varicose veins of right lower extremity with both ulcer other part of foot and inflammation 107 107 107 Yes Yes Yes No
I83218 Varicose veins of right lower extremity with both ulcer of other part of lower extremity and 107 107 107 Yes Yes Yes No
inflammation
I83219 Varicose veins of right lower extremity with both ulcer of unspecified site and inflammation 107 107 107 Yes Yes Yes No
I83221 Varicose veins of left lower extremity with both ulcer of thigh and inflammation 107 107 107 Yes Yes Yes No
I83222 Varicose veins of left lower extremity with both ulcer of calf and inflammation 107 107 107 Yes Yes Yes No
I83223 Varicose veins of left lower extremity with both ulcer of ankle and inflammation 107 107 107 Yes Yes Yes No
I83224 Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation 107 107 107 Yes Yes Yes No
I83225 Varicose veins of left lower extremity with both ulcer other part of foot and inflammation 107 107 107 Yes Yes Yes No
I83228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and 107 107 107 Yes Yes Yes No
inflammation
I83229 Varicose veins of left lower extremity with both ulcer of unspecified site and inflammation 107 107 107 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 106 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

I8500 Esophageal varices without bleeding 27 27 27 Yes Yes Yes No


I8501 Esophageal varices with bleeding 27 27 27 Yes Yes Yes No
I8510 Secondary esophageal varices without bleeding 27 27 27 Yes Yes Yes No
I8511 Secondary esophageal varices with bleeding 27 27 27 Yes Yes Yes No
I87011 Postthrombotic syndrome with ulcer of right lower extremity 107 107 107 Yes Yes Yes No
I87012 Postthrombotic syndrome with ulcer of left lower extremity 107 107 107 Yes Yes Yes No
I87013 Postthrombotic syndrome with ulcer of bilateral lower extremity 107 107 107 Yes Yes Yes No
I87019 Postthrombotic syndrome with ulcer of unspecified lower extremity 107 107 107 Yes Yes Yes No
I87031 Postthrombotic syndrome with ulcer and inflammation of right lower extremity 107 107 107 Yes Yes Yes No
I87032 Postthrombotic syndrome with ulcer and inflammation of left lower extremity 107 107 107 Yes Yes Yes No
I87033 Postthrombotic syndrome with ulcer and inflammation of bilateral lower extremity 107 107 107 Yes Yes Yes No
I87039 Postthrombotic syndrome with ulcer and inflammation of unspecified lower extremity 107 107 107 Yes Yes Yes No
I87311 Chronic venous hypertension (idiopathic) with ulcer of right lower extremity 107 107 107 Yes Yes Yes No
I87312 Chronic venous hypertension (idiopathic) with ulcer of left lower extremity 107 107 107 Yes Yes Yes No
I87313 Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity 107 107 107 Yes Yes Yes No
I87319 Chronic venous hypertension (idiopathic) with ulcer of unspecified lower extremity 107 107 107 Yes Yes Yes No
I87331 Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity 107 107 107 Yes Yes Yes No
I87332 Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity 107 107 107 Yes Yes Yes No
I87333 Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity 107 107 107 Yes Yes Yes No
I87339 Chronic venous hypertension (idiopathic) with ulcer and inflammation of unspecified lower extremity 107 107 107 Yes Yes Yes No

I96 Gangrene, not elsewhere classified 106 106 106 Yes Yes Yes No
I97810 Intraoperative cerebrovascular infarction during cardiac surgery 100 100 100 206 Yes Yes Yes Yes
I97811 Intraoperative cerebrovascular infarction during other surgery 100 100 100 206 Yes Yes Yes Yes
I97820 Postprocedural cerebrovascular infarction following cardiac surgery 100 100 100 206 Yes Yes Yes Yes
I97821 Postprocedural cerebrovascular infarction following other surgery 100 100 100 206 Yes Yes Yes Yes
J13 Pneumonia due to Streptococcus pneumoniae 115 115 115 Yes Yes Yes No
J14 Pneumonia due to Hemophilus influenzae 115 115 115 Yes Yes Yes No
J150 Pneumonia due to Klebsiella pneumoniae 114 114 114 Yes Yes Yes No
J151 Pneumonia due to Pseudomonas 114 114 114 Yes Yes Yes No
J1520 Pneumonia due to staphylococcus, unspecified 114 114 114 Yes Yes Yes No
J15211 Pneumonia due to Methicillin susceptible Staphylococcus aureus 114 114 114 Yes Yes Yes No
J15212 Pneumonia due to Methicillin resistant Staphylococcus aureus 114 114 114 Yes Yes Yes No
J1529 Pneumonia due to other staphylococcus 114 114 114 Yes Yes Yes No
J153 Pneumonia due to streptococcus, group B 115 115 115 Yes Yes Yes No
J154 Pneumonia due to other streptococci 115 115 115 Yes Yes Yes No
J155 Pneumonia due to Escherichia coli 114 114 114 Yes Yes Yes No
J156 Pneumonia due to other Gram-negative bacteria 114 114 114 Yes Yes Yes No
J158 Pneumonia due to other specified bacteria 114 114 114 Yes Yes Yes No
J181 Lobar pneumonia, unspecified organism 115 115 115 Yes Yes Yes No
J410 Simple chronic bronchitis 111 111 111 226 Yes Yes Yes Yes
J411 Mucopurulent chronic bronchitis 111 111 111 226 Yes Yes Yes Yes
J418 Mixed simple and mucopurulent chronic bronchitis 111 111 111 226 Yes Yes Yes Yes
J42 Unspecified chronic bronchitis 111 111 111 226 Yes Yes Yes Yes
J430 Unilateral pulmonary emphysema [MacLeod's syndrome] 111 111 111 226 Yes Yes Yes Yes
J431 Panlobular emphysema 111 111 111 226 Yes Yes Yes Yes
J432 Centrilobular emphysema 111 111 111 226 Yes Yes Yes Yes
J438 Other emphysema 111 111 111 226 Yes Yes Yes Yes
J439 Emphysema, unspecified 111 111 111 226 Yes Yes Yes Yes
J440 Chronic obstructive pulmonary disease with (acute) lower respiratory infection 111 111 111 226 Yes Yes Yes Yes
J441 Chronic obstructive pulmonary disease with (acute) exacerbation 111 111 111 226 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 107 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

J449 Chronic obstructive pulmonary disease, unspecified 111 111 111 226 Yes Yes Yes Yes
J4520 Mild intermittent asthma, uncomplicated 226 No No No Yes
J4521 Mild intermittent asthma with (acute) exacerbation 226 No No No Yes
J4522 Mild intermittent asthma with status asthmaticus 226 No No No Yes
J4530 Mild persistent asthma, uncomplicated 226 No No No Yes
J4531 Mild persistent asthma with (acute) exacerbation 226 No No No Yes
J4532 Mild persistent asthma with status asthmaticus 226 No No No Yes
J4540 Moderate persistent asthma, uncomplicated 226 No No No Yes
J4541 Moderate persistent asthma with (acute) exacerbation 226 No No No Yes
J4542 Moderate persistent asthma with status asthmaticus 226 No No No Yes
J4550 Severe persistent asthma, uncomplicated 226 No No No Yes
J4551 Severe persistent asthma with (acute) exacerbation 226 No No No Yes
J4552 Severe persistent asthma with status asthmaticus 226 No No No Yes
J45901 Unspecified asthma with (acute) exacerbation 226 No No No Yes
J45902 Unspecified asthma with status asthmaticus 226 No No No Yes
J45909 Unspecified asthma, uncomplicated 226 No No No Yes
J45990 Exercise induced bronchospasm 226 No No No Yes
J45991 Cough variant asthma 226 No No No Yes
J45998 Other asthma 226 No No No Yes
J470 Bronchiectasis with acute lower respiratory infection 112 112 112 227 Yes Yes Yes Yes
J471 Bronchiectasis with (acute) exacerbation 112 112 112 227 Yes Yes Yes Yes
J479 Bronchiectasis, uncomplicated 112 112 112 227 Yes Yes Yes Yes
J60 Coalworker's pneumoconiosis 112 112 112 Yes Yes Yes No
J61 Pneumoconiosis due to asbestos and other mineral fibers 112 112 112 Yes Yes Yes No
J620 Pneumoconiosis due to talc dust 112 112 112 Yes Yes Yes No
J628 Pneumoconiosis due to other dust containing silica 112 112 112 Yes Yes Yes No
J630 Aluminosis (of lung) 112 112 112 Yes Yes Yes No
J631 Bauxite fibrosis (of lung) 112 112 112 Yes Yes Yes No
J632 Berylliosis 112 112 112 Yes Yes Yes No
J633 Graphite fibrosis (of lung) 112 112 112 Yes Yes Yes No
J634 Siderosis 112 112 112 Yes Yes Yes No
J635 Stannosis 112 112 112 Yes Yes Yes No
J636 Pneumoconiosis due to other specified inorganic dusts 112 112 112 Yes Yes Yes No
J64 Unspecified pneumoconiosis 112 112 112 Yes Yes Yes No
J65 Pneumoconiosis associated with tuberculosis 112 112 112 Yes Yes Yes No
J660 Byssinosis 112 112 112 Yes Yes Yes No
J661 Flax-dressers' disease 112 112 112 Yes Yes Yes No
J662 Cannabinosis 112 112 112 Yes Yes Yes No
J668 Airway disease due to other specific organic dusts 112 112 112 Yes Yes Yes No
J670 Farmer's lung 112 112 112 Yes Yes Yes No
J671 Bagassosis 112 112 112 Yes Yes Yes No
J672 Bird fancier's lung 112 112 112 Yes Yes Yes No
J673 Suberosis 112 112 112 Yes Yes Yes No
J674 Maltworker's lung 112 112 112 Yes Yes Yes No
J675 Mushroom-worker's lung 112 112 112 Yes Yes Yes No
J676 Maple-bark-stripper's lung 112 112 112 Yes Yes Yes No
J677 Air conditioner and humidifier lung 112 112 112 Yes Yes Yes No
J678 Hypersensitivity pneumonitis due to other organic dusts 112 112 112 Yes Yes Yes No
J679 Hypersensitivity pneumonitis due to unspecified organic dust 112 112 112 Yes Yes Yes No
J680 Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors 112 112 112 Yes Yes Yes No
J681 Pulmonary edema due to chemicals, gases, fumes and vapors 112 112 112 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 108 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

J682 Upper respiratory inflammation due to chemicals, gases, fumes and vapors, not elsewhere classified 112 112 112 Yes Yes Yes No
J683 Other acute and subacute respiratory conditions due to chemicals, gases, fumes and vapors 112 112 112 Yes Yes Yes No
J684 Chronic respiratory conditions due to chemicals, gases, fumes and vapors 112 112 112 Yes Yes Yes No
J688 Other respiratory conditions due to chemicals, gases, fumes and vapors 112 112 112 Yes Yes Yes No
J689 Unspecified respiratory condition due to chemicals, gases, fumes and vapors 112 112 112 Yes Yes Yes No
J690 Pneumonitis due to inhalation of food and vomit 114 114 114 Yes Yes Yes No
J691 Pneumonitis due to inhalation of oils and essences 114 114 114 Yes Yes Yes No
J698 Pneumonitis due to inhalation of other solids and liquids 114 114 114 Yes Yes Yes No
J700 Acute pulmonary manifestations due to radiation 112 112 112 227 Yes Yes Yes Yes
J701 Chronic and other pulmonary manifestations due to radiation 112 112 112 227 Yes Yes Yes Yes
J702 Acute drug-induced interstitial lung disorders 112 112 112 227 Yes Yes Yes Yes
J703 Chronic drug-induced interstitial lung disorders 112 112 112 227 Yes Yes Yes Yes
J704 Drug-induced interstitial lung disorders, unspecified 112 112 112 227 Yes Yes Yes Yes
J705 Respiratory conditions due to smoke inhalation 112 112 112 227 Yes Yes Yes Yes
J708 Respiratory conditions due to other specified external agents 112 112 112 227 Yes Yes Yes Yes
J709 Respiratory conditions due to unspecified external agent 112 112 112 227 Yes Yes Yes Yes
J80 Acute respiratory distress syndrome 84 84 84 Yes Yes Yes No
J810 Acute pulmonary edema 84 84 84 Yes Yes Yes No
J82 Pulmonary eosinophilia, not elsewhere classified 112 112 112 Yes Yes Yes No
J8281 Chronic eosinophilic pneumonia 111 111 111 226 Yes Yes Yes Yes
J8283 Eosinophilic asthma 226 No No No Yes
J8289 Other pulmonary eosinophilia, not elsewhere classified 112 112 112 Yes Yes Yes No
J8401 Alveolar proteinosis 112 112 112 227 Yes Yes Yes Yes
J8402 Pulmonary alveolar microlithiasis 112 112 112 227 Yes Yes Yes Yes
J8403 Idiopathic pulmonary hemosiderosis 112 112 112 227 Yes Yes Yes Yes
J8409 Other alveolar and parieto-alveolar conditions 112 112 112 227 Yes Yes Yes Yes
J8410 Pulmonary fibrosis, unspecified 112 112 112 227 Yes Yes Yes Yes
J84111 Idiopathic interstitial pneumonia, not otherwise specified 112 112 112 227 Yes Yes Yes Yes
J84112 Idiopathic pulmonary fibrosis 112 112 112 227 Yes Yes Yes Yes
J84113 Idiopathic non-specific interstitial pneumonitis 112 112 112 227 Yes Yes Yes Yes
J84114 Acute interstitial pneumonitis 112 112 112 227 Yes Yes Yes Yes
J84115 Respiratory bronchiolitis interstitial lung disease 112 112 112 227 Yes Yes Yes Yes
J84116 Cryptogenic organizing pneumonia 112 112 112 227 Yes Yes Yes Yes
J84117 Desquamative interstitial pneumonia 112 112 112 227 Yes Yes Yes Yes
J8417 Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere 112 112 112 227 Yes Yes Yes Yes
J84170 Interstitial lung disease with progressive fibrotic phenotype in diseases classified elsewhere 112 112 112 227 Yes Yes Yes Yes
J84178 Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere 112 112 112 227 Yes Yes Yes Yes
J842 Lymphoid interstitial pneumonia 112 112 112 227 Yes Yes Yes Yes
J8481 Lymphangioleiomyomatosis 112 112 112 227 Yes Yes Yes Yes
J8482 Adult pulmonary Langerhans cell histiocytosis 112 112 112 227 Yes Yes Yes Yes
J8483 Surfactant mutations of the lung 112 112 112 227 Yes Yes Yes Yes
J84841 Neuroendocrine cell hyperplasia of infancy 112 112 112 227 Yes Yes Yes Yes
J84842 Pulmonary interstitial glycogenosis 112 112 112 227 Yes Yes Yes Yes
J84843 Alveolar capillary dysplasia with vein misalignment 112 112 112 227 Yes Yes Yes Yes
J84848 Other interstitial lung diseases of childhood 112 112 112 227 Yes Yes Yes Yes
J8489 Other specified interstitial pulmonary diseases 112 112 112 227 Yes Yes Yes Yes
J849 Interstitial pulmonary disease, unspecified 112 112 112 227 Yes Yes Yes Yes
J850 Gangrene and necrosis of lung 115 115 115 Yes Yes Yes No
J851 Abscess of lung with pneumonia 115 115 115 Yes Yes Yes No
J852 Abscess of lung without pneumonia 115 115 115 Yes Yes Yes No
J853 Abscess of mediastinum 115 115 115 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 109 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

J860 Pyothorax with fistula 115 115 115 Yes Yes Yes No
J869 Pyothorax without fistula 115 115 115 Yes Yes Yes No
J9500 Unspecified tracheostomy complication 82 82 82 Yes Yes Yes No
J9501 Hemorrhage from tracheostomy stoma 82 82 82 Yes Yes Yes No
J9502 Infection of tracheostomy stoma 82 82 82 Yes Yes Yes No
J9503 Malfunction of tracheostomy stoma 82 82 82 Yes Yes Yes No
J9504 Tracheo-esophageal fistula following tracheostomy 82 82 82 Yes Yes Yes No
J9509 Other tracheostomy complication 82 82 82 Yes Yes Yes No
J951 Acute pulmonary insufficiency following thoracic surgery 84 84 84 Yes Yes Yes No
J952 Acute pulmonary insufficiency following nonthoracic surgery 84 84 84 Yes Yes Yes No
J953 Chronic pulmonary insufficiency following surgery 84 84 84 Yes Yes Yes No
J95821 Acute postprocedural respiratory failure 84 84 84 Yes Yes Yes No
J95822 Acute and chronic postprocedural respiratory failure 84 84 84 Yes Yes Yes No
J95850 Mechanical complication of respirator 82 82 82 Yes Yes Yes No
J95851 Ventilator associated pneumonia 114 114 114 Yes Yes Yes No
J95859 Other complication of respirator [ventilator] 82 82 82 Yes Yes Yes No
J9600 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia 84 84 84 Yes Yes Yes No
J9601 Acute respiratory failure with hypoxia 84 84 84 Yes Yes Yes No
J9602 Acute respiratory failure with hypercapnia 84 84 84 Yes Yes Yes No
J9610 Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia 84 84 84 Yes Yes Yes No
J9611 Chronic respiratory failure with hypoxia 84 84 84 Yes Yes Yes No
J9612 Chronic respiratory failure with hypercapnia 84 84 84 Yes Yes Yes No
J9620 Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia 84 84 84 Yes Yes Yes No
J9621 Acute and chronic respiratory failure with hypoxia 84 84 84 Yes Yes Yes No
J9622 Acute and chronic respiratory failure with hypercapnia 84 84 84 Yes Yes Yes No
J9690 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia 84 84 84 Yes Yes Yes No
J9691 Respiratory failure, unspecified with hypoxia 84 84 84 Yes Yes Yes No
J9692 Respiratory failure, unspecified with hypercapnia 84 84 84 Yes Yes Yes No
J982 Interstitial emphysema 111 111 111 226 Yes Yes Yes Yes
J983 Compensatory emphysema 111 111 111 226 Yes Yes Yes Yes
J99 Respiratory disorders in diseases classified elsewhere 112 112 112 227 Yes Yes Yes Yes
K200 Eosinophilic esophagitis 68 No No No Yes
K208 Other esophagitis 68 No No No Yes
K2080 Other esophagitis without bleeding 68 No No No Yes
K2081 Other esophagitis with bleeding 68 No No No Yes
K209 Esophagitis, unspecified 68 No No No Yes
K2090 Esophagitis, unspecified without bleeding 68 No No No Yes
K2091 Esophagitis, unspecified with bleeding 68 No No No Yes
K210 Gastro-esophageal reflux disease with esophagitis 68 No No No Yes
K2100 Gastro-esophageal reflux disease with esophagitis, without bleeding 68 No No No Yes
K2101 Gastro-esophageal reflux disease with esophagitis, with bleeding 68 No No No Yes
K219 Gastro-esophageal reflux disease without esophagitis 68 No No No Yes
K220 Achalasia of cardia 68 No No No Yes
K222 Esophageal obstruction 68 No No No Yes
K223 Perforation of esophagus 68 No No No Yes
K224 Dyskinesia of esophagus 68 No No No Yes
K225 Diverticulum of esophagus, acquired 68 No No No Yes
K2270 Barrett's esophagus without dysplasia 68 No No No Yes
K22710 Barrett's esophagus with low grade dysplasia 68 No No No Yes
K22711 Barrett's esophagus with high grade dysplasia 68 No No No Yes
K22719 Barrett's esophagus with dysplasia, unspecified 68 No No No Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 110 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

K228 Other specified diseases of esophagus 68 No No No Yes


K229 Disease of esophagus, unspecified 68 No No No Yes
K23 Disorders of esophagus in diseases classified elsewhere 68 No No No Yes
K251 Acute gastric ulcer with perforation 33 33 33 Yes Yes Yes No
K252 Acute gastric ulcer with both hemorrhage and perforation 33 33 33 Yes Yes Yes No
K255 Chronic or unspecified gastric ulcer with perforation 33 33 33 Yes Yes Yes No
K256 Chronic or unspecified gastric ulcer with both hemorrhage and perforation 33 33 33 Yes Yes Yes No
K261 Acute duodenal ulcer with perforation 33 33 33 Yes Yes Yes No
K262 Acute duodenal ulcer with both hemorrhage and perforation 33 33 33 Yes Yes Yes No
K265 Chronic or unspecified duodenal ulcer with perforation 33 33 33 Yes Yes Yes No
K266 Chronic or unspecified duodenal ulcer with both hemorrhage and perforation 33 33 33 Yes Yes Yes No
K271 Acute peptic ulcer, site unspecified, with perforation 33 33 33 Yes Yes Yes No
K272 Acute peptic ulcer, site unspecified, with both hemorrhage and perforation 33 33 33 Yes Yes Yes No
K275 Chronic or unspecified peptic ulcer, site unspecified, with perforation 33 33 33 Yes Yes Yes No
K276 Chronic or unspecified peptic ulcer, site unspecified, with both hemorrhage and perforation 33 33 33 Yes Yes Yes No
K281 Acute gastrojejunal ulcer with perforation 33 33 33 Yes Yes Yes No
K282 Acute gastrojejunal ulcer with both hemorrhage and perforation 33 33 33 Yes Yes Yes No
K285 Chronic or unspecified gastrojejunal ulcer with perforation 33 33 33 Yes Yes Yes No
K286 Chronic or unspecified gastrojejunal ulcer with both hemorrhage and perforation 33 33 33 Yes Yes Yes No
K5000 Crohn's disease of small intestine without complications 35 35 35 67 Yes Yes Yes Yes
K50011 Crohn's disease of small intestine with rectal bleeding 35 35 35 67 Yes Yes Yes Yes
K50012 Crohn's disease of small intestine with intestinal obstruction 33 33 33 67 Yes Yes Yes Yes
K50012 Crohn's disease of small intestine with intestinal obstruction 35 35 35 Yes Yes Yes --
K50013 Crohn's disease of small intestine with fistula 35 35 35 67 Yes Yes Yes Yes
K50014 Crohn's disease of small intestine with abscess 35 35 35 67 Yes Yes Yes Yes
K50018 Crohn's disease of small intestine with other complication 35 35 35 67 Yes Yes Yes Yes
K50019 Crohn's disease of small intestine with unspecified complications 35 35 35 67 Yes Yes Yes Yes
K5010 Crohn's disease of large intestine without complications 35 35 35 67 Yes Yes Yes Yes
K50111 Crohn's disease of large intestine with rectal bleeding 35 35 35 67 Yes Yes Yes Yes
K50112 Crohn's disease of large intestine with intestinal obstruction 33 33 33 67 Yes Yes Yes Yes
K50112 Crohn's disease of large intestine with intestinal obstruction 35 35 35 Yes Yes Yes --
K50113 Crohn's disease of large intestine with fistula 35 35 35 67 Yes Yes Yes Yes
K50114 Crohn's disease of large intestine with abscess 35 35 35 67 Yes Yes Yes Yes
K50118 Crohn's disease of large intestine with other complication 35 35 35 67 Yes Yes Yes Yes
K50119 Crohn's disease of large intestine with unspecified complications 35 35 35 67 Yes Yes Yes Yes
K5080 Crohn's disease of both small and large intestine without complications 35 35 35 67 Yes Yes Yes Yes
K50811 Crohn's disease of both small and large intestine with rectal bleeding 35 35 35 67 Yes Yes Yes Yes
K50812 Crohn's disease of both small and large intestine with intestinal obstruction 33 33 33 67 Yes Yes Yes Yes
K50812 Crohn's disease of both small and large intestine with intestinal obstruction 35 35 35 Yes Yes Yes --
K50813 Crohn's disease of both small and large intestine with fistula 35 35 35 67 Yes Yes Yes Yes
K50814 Crohn's disease of both small and large intestine with abscess 35 35 35 67 Yes Yes Yes Yes
K50818 Crohn's disease of both small and large intestine with other complication 35 35 35 67 Yes Yes Yes Yes
K50819 Crohn's disease of both small and large intestine with unspecified complications 35 35 35 67 Yes Yes Yes Yes
K5090 Crohn's disease, unspecified, without complications 35 35 35 67 Yes Yes Yes Yes
K50911 Crohn's disease, unspecified, with rectal bleeding 35 35 35 67 Yes Yes Yes Yes
K50912 Crohn's disease, unspecified, with intestinal obstruction 33 33 33 67 Yes Yes Yes Yes
K50912 Crohn's disease, unspecified, with intestinal obstruction 35 35 35 Yes Yes Yes --
K50913 Crohn's disease, unspecified, with fistula 35 35 35 67 Yes Yes Yes Yes
K50914 Crohn's disease, unspecified, with abscess 35 35 35 67 Yes Yes Yes Yes
K50918 Crohn's disease, unspecified, with other complication 35 35 35 67 Yes Yes Yes Yes
K50919 Crohn's disease, unspecified, with unspecified complications 35 35 35 67 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 111 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

K5100 Ulcerative (chronic) pancolitis without complications 35 35 35 67 Yes Yes Yes Yes
K51011 Ulcerative (chronic) pancolitis with rectal bleeding 35 35 35 67 Yes Yes Yes Yes
K51012 Ulcerative (chronic) pancolitis with intestinal obstruction 33 33 33 67 Yes Yes Yes Yes
K51012 Ulcerative (chronic) pancolitis with intestinal obstruction 35 35 35 Yes Yes Yes --
K51013 Ulcerative (chronic) pancolitis with fistula 35 35 35 67 Yes Yes Yes Yes
K51014 Ulcerative (chronic) pancolitis with abscess 35 35 35 67 Yes Yes Yes Yes
K51018 Ulcerative (chronic) pancolitis with other complication 35 35 35 67 Yes Yes Yes Yes
K51019 Ulcerative (chronic) pancolitis with unspecified complications 35 35 35 67 Yes Yes Yes Yes
K5120 Ulcerative (chronic) proctitis without complications 35 35 35 67 Yes Yes Yes Yes
K51211 Ulcerative (chronic) proctitis with rectal bleeding 35 35 35 67 Yes Yes Yes Yes
K51212 Ulcerative (chronic) proctitis with intestinal obstruction 33 33 33 67 Yes Yes Yes Yes
K51212 Ulcerative (chronic) proctitis with intestinal obstruction 35 35 35 Yes Yes Yes --
K51213 Ulcerative (chronic) proctitis with fistula 35 35 35 67 Yes Yes Yes Yes
K51214 Ulcerative (chronic) proctitis with abscess 35 35 35 67 Yes Yes Yes Yes
K51218 Ulcerative (chronic) proctitis with other complication 35 35 35 67 Yes Yes Yes Yes
K51219 Ulcerative (chronic) proctitis with unspecified complications 35 35 35 67 Yes Yes Yes Yes
K5130 Ulcerative (chronic) rectosigmoiditis without complications 35 35 35 67 Yes Yes Yes Yes
K51311 Ulcerative (chronic) rectosigmoiditis with rectal bleeding 35 35 35 67 Yes Yes Yes Yes
K51312 Ulcerative (chronic) rectosigmoiditis with intestinal obstruction 33 33 33 67 Yes Yes Yes Yes
K51312 Ulcerative (chronic) rectosigmoiditis with intestinal obstruction 35 35 35 Yes Yes Yes --
K51313 Ulcerative (chronic) rectosigmoiditis with fistula 35 35 35 67 Yes Yes Yes Yes
K51314 Ulcerative (chronic) rectosigmoiditis with abscess 35 35 35 67 Yes Yes Yes Yes
K51318 Ulcerative (chronic) rectosigmoiditis with other complication 35 35 35 67 Yes Yes Yes Yes
K51319 Ulcerative (chronic) rectosigmoiditis with unspecified complications 35 35 35 67 Yes Yes Yes Yes
K5140 Inflammatory polyps of colon without complications 35 35 35 67 Yes Yes Yes Yes
K51411 Inflammatory polyps of colon with rectal bleeding 35 35 35 67 Yes Yes Yes Yes
K51412 Inflammatory polyps of colon with intestinal obstruction 33 33 33 67 Yes Yes Yes Yes
K51412 Inflammatory polyps of colon with intestinal obstruction 35 35 35 Yes Yes Yes --
K51413 Inflammatory polyps of colon with fistula 35 35 35 67 Yes Yes Yes Yes
K51414 Inflammatory polyps of colon with abscess 35 35 35 67 Yes Yes Yes Yes
K51418 Inflammatory polyps of colon with other complication 35 35 35 67 Yes Yes Yes Yes
K51419 Inflammatory polyps of colon with unspecified complications 35 35 35 67 Yes Yes Yes Yes
K5150 Left sided colitis without complications 35 35 35 67 Yes Yes Yes Yes
K51511 Left sided colitis with rectal bleeding 35 35 35 67 Yes Yes Yes Yes
K51512 Left sided colitis with intestinal obstruction 33 33 33 67 Yes Yes Yes Yes
K51512 Left sided colitis with intestinal obstruction 35 35 35 Yes Yes Yes --
K51513 Left sided colitis with fistula 35 35 35 67 Yes Yes Yes Yes
K51514 Left sided colitis with abscess 35 35 35 67 Yes Yes Yes Yes
K51518 Left sided colitis with other complication 35 35 35 67 Yes Yes Yes Yes
K51519 Left sided colitis with unspecified complications 35 35 35 67 Yes Yes Yes Yes
K5180 Other ulcerative colitis without complications 35 35 35 67 Yes Yes Yes Yes
K51811 Other ulcerative colitis with rectal bleeding 35 35 35 67 Yes Yes Yes Yes
K51812 Other ulcerative colitis with intestinal obstruction 33 33 33 67 Yes Yes Yes Yes
K51812 Other ulcerative colitis with intestinal obstruction 35 35 35 Yes Yes Yes --
K51813 Other ulcerative colitis with fistula 35 35 35 67 Yes Yes Yes Yes
K51814 Other ulcerative colitis with abscess 35 35 35 67 Yes Yes Yes Yes
K51818 Other ulcerative colitis with other complication 35 35 35 67 Yes Yes Yes Yes
K51819 Other ulcerative colitis with unspecified complications 35 35 35 67 Yes Yes Yes Yes
K5190 Ulcerative colitis, unspecified, without complications 35 35 35 67 Yes Yes Yes Yes
K51911 Ulcerative colitis, unspecified with rectal bleeding 35 35 35 67 Yes Yes Yes Yes
K51912 Ulcerative colitis, unspecified with intestinal obstruction 33 33 33 67 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 112 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

K51912 Ulcerative colitis, unspecified with intestinal obstruction 35 35 35 Yes Yes Yes --
K51913 Ulcerative colitis, unspecified with fistula 35 35 35 67 Yes Yes Yes Yes
K51914 Ulcerative colitis, unspecified with abscess 35 35 35 67 Yes Yes Yes Yes
K51918 Ulcerative colitis, unspecified with other complication 35 35 35 67 Yes Yes Yes Yes
K51919 Ulcerative colitis, unspecified with unspecified complications 35 35 35 67 Yes Yes Yes Yes
K55011 Focal (segmental) acute (reversible) ischemia of small intestine 107 107 107 Yes Yes Yes No
K55012 Diffuse acute (reversible) ischemia of small intestine 107 107 107 Yes Yes Yes No
K55019 Acute (reversible) ischemia of small intestine, extent unspecified 107 107 107 Yes Yes Yes No
K55021 Focal (segmental) acute infarction of small intestine 107 107 107 Yes Yes Yes No
K55022 Diffuse acute infarction of small intestine 107 107 107 Yes Yes Yes No
K55029 Acute infarction of small intestine, extent unspecified 107 107 107 Yes Yes Yes No
K55031 Focal (segmental) acute (reversible) ischemia of large intestine 107 107 107 Yes Yes Yes No
K55032 Diffuse acute (reversible) ischemia of large intestine 107 107 107 Yes Yes Yes No
K55039 Acute (reversible) ischemia of large intestine, extent unspecified 107 107 107 Yes Yes Yes No
K55041 Focal (segmental) acute infarction of large intestine 107 107 107 Yes Yes Yes No
K55042 Diffuse acute infarction of large intestine 107 107 107 Yes Yes Yes No
K55049 Acute infarction of large intestine, extent unspecified 107 107 107 Yes Yes Yes No
K55051 Focal (segmental) acute (reversible) ischemia of intestine, part unspecified 107 107 107 Yes Yes Yes No
K55052 Diffuse acute (reversible) ischemia of intestine, part unspecified 107 107 107 Yes Yes Yes No
K55059 Acute (reversible) ischemia of intestine, part and extent unspecified 107 107 107 Yes Yes Yes No
K55061 Focal (segmental) acute infarction of intestine, part unspecified 107 107 107 Yes Yes Yes No
K55062 Diffuse acute infarction of intestine, part unspecified 107 107 107 Yes Yes Yes No
K55069 Acute infarction of intestine, part and extent unspecified 107 107 107 Yes Yes Yes No
K551 Chronic vascular disorders of intestine 108 108 108 Yes Yes Yes No
K5530 Necrotizing enterocolitis, unspecified 107 107 107 Yes Yes Yes No
K5531 Stage 1 necrotizing enterocolitis 107 107 107 Yes Yes Yes No
K5532 Stage 2 necrotizing enterocolitis 107 107 107 Yes Yes Yes No
K5533 Stage 3 necrotizing enterocolitis 107 107 107 Yes Yes Yes No
K558 Other vascular disorders of intestine 108 108 108 Yes Yes Yes No
K559 Vascular disorder of intestine, unspecified 108 108 108 Yes Yes Yes No
K560 Paralytic ileus 33 33 33 Yes Yes Yes No
K561 Intussusception 33 33 33 Yes Yes Yes No
K562 Volvulus 33 33 33 Yes Yes Yes No
K563 Gallstone ileus 33 33 33 Yes Yes Yes No
K5641 Fecal impaction 33 33 33 Yes Yes Yes No
K5649 Other impaction of intestine 33 33 33 Yes Yes Yes No
K5650 Intestinal adhesions [bands], unspecified as to partial versus complete obstruction 33 33 33 Yes Yes Yes No
K5651 Intestinal adhesions [bands], with partial obstruction 33 33 33 Yes Yes Yes No
K5652 Intestinal adhesions [bands] with complete obstruction 33 33 33 Yes Yes Yes No
K56600 Partial intestinal obstruction, unspecified as to cause 33 33 33 Yes Yes Yes No
K56601 Complete intestinal obstruction, unspecified as to cause 33 33 33 Yes Yes Yes No
K56609 Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction 33 33 33 Yes Yes Yes No
K56690 Other partial intestinal obstruction 33 33 33 Yes Yes Yes No
K56691 Other complete intestinal obstruction 33 33 33 Yes Yes Yes No
K56699 Other intestinal obstruction unspecified as to partial versus complete obstruction 33 33 33 Yes Yes Yes No
K567 Ileus, unspecified 33 33 33 Yes Yes Yes No
K5931 Toxic megacolon 33 33 33 Yes Yes Yes No
K631 Perforation of intestine (nontraumatic) 33 33 33 Yes Yes Yes No
K650 Generalized (acute) peritonitis 33 33 33 Yes Yes Yes No
K651 Peritoneal abscess 33 33 33 Yes Yes Yes No
K652 Spontaneous bacterial peritonitis 33 33 33 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 113 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

K653 Choleperitonitis 33 33 33 Yes Yes Yes No


K654 Sclerosing mesenteritis 33 33 33 Yes Yes Yes No
K658 Other peritonitis 33 33 33 Yes Yes Yes No
K659 Peritonitis, unspecified 33 33 33 Yes Yes Yes No
K67 Disorders of peritoneum in infectious diseases classified elsewhere 33 33 33 Yes Yes Yes No
K6812 Psoas muscle abscess 33 33 33 Yes Yes Yes No
K6819 Other retroperitoneal abscess 33 33 33 Yes Yes Yes No
K7030 Alcoholic cirrhosis of liver without ascites 28 28 28 Yes Yes Yes No
K7031 Alcoholic cirrhosis of liver with ascites 28 28 28 Yes Yes Yes No
K7040 Alcoholic hepatic failure without coma 28 28 28 Yes Yes Yes No
K7041 Alcoholic hepatic failure with coma 27 27 27 Yes Yes Yes No
K7041 Alcoholic hepatic failure with coma 28 28 28 Yes Yes Yes No
K709 Alcoholic liver disease, unspecified 28 28 28 Yes Yes Yes No
K7111 Toxic liver disease with hepatic necrosis, with coma 27 27 27 Yes Yes Yes No
K7201 Acute and subacute hepatic failure with coma 27 27 27 Yes Yes Yes No
K7210 Chronic hepatic failure without coma 27 27 27 Yes Yes Yes No
K7211 Chronic hepatic failure with coma 27 27 27 Yes Yes Yes No
K7290 Hepatic failure, unspecified without coma 27 27 27 Yes Yes Yes No
K7291 Hepatic failure, unspecified with coma 27 27 27 Yes Yes Yes No
K730 Chronic persistent hepatitis, not elsewhere classified 29 29 29 Yes Yes Yes No
K731 Chronic lobular hepatitis, not elsewhere classified 29 29 29 Yes Yes Yes No
K732 Chronic active hepatitis, not elsewhere classified 29 29 29 Yes Yes Yes No
K738 Other chronic hepatitis, not elsewhere classified 29 29 29 Yes Yes Yes No
K739 Chronic hepatitis, unspecified 29 29 29 Yes Yes Yes No
K743 Primary biliary cirrhosis 28 28 28 Yes Yes Yes No
K744 Secondary biliary cirrhosis 28 28 28 Yes Yes Yes No
K745 Biliary cirrhosis, unspecified 28 28 28 Yes Yes Yes No
K7460 Unspecified cirrhosis of liver 28 28 28 Yes Yes Yes No
K7469 Other cirrhosis of liver 28 28 28 Yes Yes Yes No
K754 Autoimmune hepatitis 29 29 29 Yes Yes Yes No
K766 Portal hypertension 27 27 27 Yes Yes Yes No
K767 Hepatorenal syndrome 27 27 27 Yes Yes Yes No
K7681 Hepatopulmonary syndrome 27 27 27 Yes Yes Yes No
K860 Alcohol-induced chronic pancreatitis 34 34 34 65 Yes Yes Yes Yes
K861 Other chronic pancreatitis 34 34 34 65 Yes Yes Yes Yes
K862 Cyst of pancreas 66 No No No Yes
K863 Pseudocyst of pancreas 66 No No No Yes
K8681 Exocrine pancreatic insufficiency 66 No No No Yes
K8689 Other specified diseases of pancreas 66 No No No Yes
K869 Disease of pancreas, unspecified 66 No No No Yes
K87 Disorders of gallbladder, biliary tract and pancreas in diseases classified elsewhere 66 No No No Yes
K900 Celiac disease 66 No No No Yes
K901 Tropical sprue 66 No No No Yes
K902 Blind loop syndrome, not elsewhere classified 66 No No No Yes
K903 Pancreatic steatorrhea 66 No No No Yes
K9049 Malabsorption due to intolerance, not elsewhere classified 66 No No No Yes
K9081 Whipple's disease 66 No No No Yes
K9089 Other intestinal malabsorption 66 No No No Yes
K909 Intestinal malabsorption, unspecified 66 No No No Yes
K912 Postsurgical malabsorption, not elsewhere classified 66 No No No Yes
K91850 Pouchitis 188 188 188 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 114 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

K91858 Other complications of intestinal pouch 188 188 188 Yes Yes Yes No
K9400 Colostomy complication, unspecified 188 188 188 Yes Yes Yes No
K9401 Colostomy hemorrhage 188 188 188 Yes Yes Yes No
K9402 Colostomy infection 188 188 188 Yes Yes Yes No
K9403 Colostomy malfunction 188 188 188 Yes Yes Yes No
K9409 Other complications of colostomy 188 188 188 Yes Yes Yes No
K9410 Enterostomy complication, unspecified 188 188 188 Yes Yes Yes No
K9411 Enterostomy hemorrhage 188 188 188 Yes Yes Yes No
K9412 Enterostomy infection 188 188 188 Yes Yes Yes No
K9413 Enterostomy malfunction 188 188 188 Yes Yes Yes No
K9419 Other complications of enterostomy 188 188 188 Yes Yes Yes No
K9420 Gastrostomy complication, unspecified 188 188 188 Yes Yes Yes No
K9421 Gastrostomy hemorrhage 188 188 188 Yes Yes Yes No
K9422 Gastrostomy infection 188 188 188 Yes Yes Yes No
K9423 Gastrostomy malfunction 188 188 188 Yes Yes Yes No
K9429 Other complications of gastrostomy 188 188 188 Yes Yes Yes No
K9430 Esophagostomy complications, unspecified 188 188 188 Yes Yes Yes No
K9431 Esophagostomy hemorrhage 188 188 188 Yes Yes Yes No
K9432 Esophagostomy infection 188 188 188 Yes Yes Yes No
K9433 Esophagostomy malfunction 188 188 188 Yes Yes Yes No
K9439 Other complications of esophagostomy 188 188 188 Yes Yes Yes No
L100 Pemphigus vulgaris 314 No No No Yes
L101 Pemphigus vegetans 314 No No No Yes
L102 Pemphigus foliaceous 314 No No No Yes
L103 Brazilian pemphigus [fogo selvagem] 314 No No No Yes
L104 Pemphigus erythematosus 314 No No No Yes
L105 Drug-induced pemphigus 314 No No No Yes
L1081 Paraneoplastic pemphigus 314 No No No Yes
L1089 Other pemphigus 314 No No No Yes
L109 Pemphigus, unspecified 314 No No No Yes
L1230 Acquired epidermolysis bullosa, unspecified 162 162 162 Yes Yes Yes No
L1231 Epidermolysis bullosa due to drug 162 162 162 Yes Yes Yes No
L1235 Other acquired epidermolysis bullosa 162 162 162 Yes Yes Yes No
L400 Psoriasis vulgaris 316 No No No Yes
L401 Generalized pustular psoriasis 316 No No No Yes
L402 Acrodermatitis continua 316 No No No Yes
L403 Pustulosis palmaris et plantaris 316 No No No Yes
L404 Guttate psoriasis 316 No No No Yes
L4050 Arthropathic psoriasis, unspecified 40 40 40 82 Yes Yes Yes Yes
L4051 Distal interphalangeal psoriatic arthropathy 40 40 40 82 Yes Yes Yes Yes
L4052 Psoriatic arthritis mutilans 40 40 40 82 Yes Yes Yes Yes
L4053 Psoriatic spondylitis 40 40 40 82 Yes Yes Yes Yes
L4054 Psoriatic juvenile arthropathy 40 40 40 82 Yes Yes Yes Yes
L4059 Other psoriatic arthropathy 40 40 40 82 Yes Yes Yes Yes
L408 Other psoriasis 316 No No No Yes
L409 Psoriasis, unspecified 316 No No No Yes
L410 Pityriasis lichenoides et varioliformis acuta 316 No No No Yes
L411 Pityriasis lichenoides chronica 316 No No No Yes
L413 Small plaque parapsoriasis 316 No No No Yes
L414 Large plaque parapsoriasis 316 No No No Yes
L415 Retiform parapsoriasis 316 No No No Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 115 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

L418 Other parapsoriasis 316 No No No Yes


L419 Parapsoriasis, unspecified 316 No No No Yes
L511 Stevens-Johnson syndrome 162 162 162 Yes Yes Yes No
L512 Toxic epidermal necrolysis [Lyell] 162 162 162 Yes Yes Yes No
L513 Stevens-Johnson syndrome-toxic epidermal necrolysis overlap syndrome 162 162 162 Yes Yes Yes No
L89000 Pressure ulcer of unspecified elbow, unstageable 158 158 158 Yes Yes Yes No
L89000 Pressure ulcer of unspecified elbow, unstageable 160 Yes -- -- No
L89001 Pressure ulcer of unspecified elbow, stage 1 160 Yes No No No
L89002 Pressure ulcer of unspecified elbow, stage 2 159 159 Yes No Yes No
L89002 Pressure ulcer of unspecified elbow, stage 2 160 Yes No -- No
L89003 Pressure ulcer of unspecified elbow, stage 3 158 158 158 Yes Yes Yes No
L89003 Pressure ulcer of unspecified elbow, stage 3 160 Yes -- -- No
L89004 Pressure ulcer of unspecified elbow, stage 4 157 157 157 Yes Yes Yes No
L89004 Pressure ulcer of unspecified elbow, stage 4 160 Yes -- -- No
L89006 Pressure-induced deep tissue damage of unspecified elbow 160 Yes No No No
L89009 Pressure ulcer of unspecified elbow, unspecified stage 160 Yes No No No
L89010 Pressure ulcer of right elbow, unstageable 158 158 158 Yes Yes Yes No
L89010 Pressure ulcer of right elbow, unstageable 160 Yes -- -- No
L89011 Pressure ulcer of right elbow, stage 1 160 Yes No No No
L89012 Pressure ulcer of right elbow, stage 2 159 159 Yes No Yes No
L89012 Pressure ulcer of right elbow, stage 2 160 Yes No -- No
L89013 Pressure ulcer of right elbow, stage 3 158 158 158 Yes Yes Yes No
L89013 Pressure ulcer of right elbow, stage 3 160 Yes -- -- No
L89014 Pressure ulcer of right elbow, stage 4 157 157 157 Yes Yes Yes No
L89014 Pressure ulcer of right elbow, stage 4 160 Yes -- -- No
L89016 Pressure-induced deep tissue damage of right elbow 160 Yes No No No
L89019 Pressure ulcer of right elbow, unspecified stage 160 Yes No No No
L89020 Pressure ulcer of left elbow, unstageable 158 158 158 Yes Yes Yes No
L89020 Pressure ulcer of left elbow, unstageable 160 Yes -- -- No
L89021 Pressure ulcer of left elbow, stage 1 160 Yes No No No
L89022 Pressure ulcer of left elbow, stage 2 159 159 Yes No Yes No
L89022 Pressure ulcer of left elbow, stage 2 160 Yes No -- No
L89023 Pressure ulcer of left elbow, stage 3 158 158 158 Yes Yes Yes No
L89023 Pressure ulcer of left elbow, stage 3 160 Yes -- -- No
L89024 Pressure ulcer of left elbow, stage 4 157 157 157 Yes Yes Yes No
L89024 Pressure ulcer of left elbow, stage 4 160 Yes -- -- No
L89026 Pressure-induced deep tissue damage of left elbow 160 Yes No No No
L89029 Pressure ulcer of left elbow, unspecified stage 160 Yes No No No
L89100 Pressure ulcer of unspecified part of back, unstageable 158 158 158 Yes Yes Yes No
L89100 Pressure ulcer of unspecified part of back, unstageable 160 Yes -- -- No
L89101 Pressure ulcer of unspecified part of back, stage 1 160 Yes No No No
L89102 Pressure ulcer of unspecified part of back, stage 2 159 159 Yes No Yes No
L89102 Pressure ulcer of unspecified part of back, stage 2 160 Yes No -- No
L89103 Pressure ulcer of unspecified part of back, stage 3 158 158 158 Yes Yes Yes No
L89103 Pressure ulcer of unspecified part of back, stage 3 160 Yes -- -- No
L89104 Pressure ulcer of unspecified part of back, stage 4 157 157 157 Yes Yes Yes No
L89104 Pressure ulcer of unspecified part of back, stage 4 160 Yes -- -- No
L89106 Pressure-induced deep tissue damage of unspecified part of back 160 Yes No No No
L89109 Pressure ulcer of unspecified part of back, unspecified stage 160 Yes No No No
L89110 Pressure ulcer of right upper back, unstageable 158 158 158 Yes Yes Yes No
L89110 Pressure ulcer of right upper back, unstageable 160 Yes -- -- No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 116 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

L89111 Pressure ulcer of right upper back, stage 1 160 Yes No No No


L89112 Pressure ulcer of right upper back, stage 2 159 159 Yes No Yes No
L89112 Pressure ulcer of right upper back, stage 2 160 Yes No -- No
L89113 Pressure ulcer of right upper back, stage 3 158 158 158 Yes Yes Yes No
L89113 Pressure ulcer of right upper back, stage 3 160 Yes -- -- No
L89114 Pressure ulcer of right upper back, stage 4 157 157 157 Yes Yes Yes No
L89114 Pressure ulcer of right upper back, stage 4 160 Yes -- -- No
L89116 Pressure-induced deep tissue damage of right upper back 160 Yes No No No
L89119 Pressure ulcer of right upper back, unspecified stage 160 Yes No No No
L89120 Pressure ulcer of left upper back, unstageable 158 158 158 Yes Yes Yes No
L89120 Pressure ulcer of left upper back, unstageable 160 Yes -- -- No
L89121 Pressure ulcer of left upper back, stage 1 160 Yes No No No
L89122 Pressure ulcer of left upper back, stage 2 159 159 Yes No Yes No
L89122 Pressure ulcer of left upper back, stage 2 160 Yes No -- No
L89123 Pressure ulcer of left upper back, stage 3 158 158 158 Yes Yes Yes No
L89123 Pressure ulcer of left upper back, stage 3 160 Yes -- -- No
L89124 Pressure ulcer of left upper back, stage 4 157 157 157 Yes Yes Yes No
L89124 Pressure ulcer of left upper back, stage 4 160 Yes -- -- No
L89126 Pressure-induced deep tissue damage of left upper back 160 Yes No No No
L89129 Pressure ulcer of left upper back, unspecified stage 160 Yes No No No
L89130 Pressure ulcer of right lower back, unstageable 158 158 158 Yes Yes Yes No
L89130 Pressure ulcer of right lower back, unstageable 160 Yes -- -- No
L89131 Pressure ulcer of right lower back, stage 1 160 Yes No No No
L89132 Pressure ulcer of right lower back, stage 2 159 159 Yes No Yes No
L89132 Pressure ulcer of right lower back, stage 2 160 Yes No -- No
L89133 Pressure ulcer of right lower back, stage 3 158 158 158 Yes Yes Yes No
L89133 Pressure ulcer of right lower back, stage 3 160 Yes -- -- No
L89134 Pressure ulcer of right lower back, stage 4 157 157 157 Yes Yes Yes No
L89134 Pressure ulcer of right lower back, stage 4 160 Yes -- -- No
L89136 Pressure-induced deep tissue damage of right lower back 160 Yes No No No
L89139 Pressure ulcer of right lower back, unspecified stage 160 Yes No No No
L89140 Pressure ulcer of left lower back, unstageable 158 158 158 Yes Yes Yes No
L89140 Pressure ulcer of left lower back, unstageable 160 Yes -- -- No
L89141 Pressure ulcer of left lower back, stage 1 160 Yes No No No
L89142 Pressure ulcer of left lower back, stage 2 159 159 Yes No Yes No
L89142 Pressure ulcer of left lower back, stage 2 160 Yes No -- No
L89143 Pressure ulcer of left lower back, stage 3 158 158 158 Yes Yes Yes No
L89143 Pressure ulcer of left lower back, stage 3 160 Yes -- -- No
L89144 Pressure ulcer of left lower back, stage 4 157 157 157 Yes Yes Yes No
L89144 Pressure ulcer of left lower back, stage 4 160 Yes -- -- No
L89146 Pressure-induced deep tissue damage of left lower back 160 Yes No No No
L89149 Pressure ulcer of left lower back, unspecified stage 160 Yes No No No
L89150 Pressure ulcer of sacral region, unstageable 158 158 158 Yes Yes Yes No
L89150 Pressure ulcer of sacral region, unstageable 160 Yes -- -- No
L89151 Pressure ulcer of sacral region, stage 1 160 Yes No No No
L89152 Pressure ulcer of sacral region, stage 2 159 159 Yes No Yes No
L89152 Pressure ulcer of sacral region, stage 2 160 Yes No -- No
L89153 Pressure ulcer of sacral region, stage 3 158 158 158 Yes Yes Yes No
L89153 Pressure ulcer of sacral region, stage 3 160 Yes -- -- No
L89154 Pressure ulcer of sacral region, stage 4 157 157 157 Yes Yes Yes No
L89154 Pressure ulcer of sacral region, stage 4 160 Yes -- -- No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 117 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

L89156 Pressure-induced deep tissue damage of sacral region 160 Yes No No No


L89159 Pressure ulcer of sacral region, unspecified stage 160 Yes No No No
L89200 Pressure ulcer of unspecified hip, unstageable 158 158 158 Yes Yes Yes No
L89200 Pressure ulcer of unspecified hip, unstageable 160 Yes -- -- No
L89201 Pressure ulcer of unspecified hip, stage 1 160 Yes No No No
L89202 Pressure ulcer of unspecified hip, stage 2 159 159 Yes No Yes No
L89202 Pressure ulcer of unspecified hip, stage 2 160 Yes No -- No
L89203 Pressure ulcer of unspecified hip, stage 3 158 158 158 Yes Yes Yes No
L89203 Pressure ulcer of unspecified hip, stage 3 160 Yes -- -- No
L89204 Pressure ulcer of unspecified hip, stage 4 157 157 157 Yes Yes Yes No
L89204 Pressure ulcer of unspecified hip, stage 4 160 Yes -- -- No
L89206 Pressure-induced deep tissue damage of unspecified hip 160 Yes No No No
L89209 Pressure ulcer of unspecified hip, unspecified stage 160 Yes No No No
L89210 Pressure ulcer of right hip, unstageable 158 158 158 Yes Yes Yes No
L89210 Pressure ulcer of right hip, unstageable 160 Yes -- -- No
L89211 Pressure ulcer of right hip, stage 1 160 Yes No No No
L89212 Pressure ulcer of right hip, stage 2 159 159 Yes No Yes No
L89212 Pressure ulcer of right hip, stage 2 160 Yes No -- No
L89213 Pressure ulcer of right hip, stage 3 158 158 158 Yes Yes Yes No
L89213 Pressure ulcer of right hip, stage 3 160 Yes -- -- No
L89214 Pressure ulcer of right hip, stage 4 157 157 157 Yes Yes Yes No
L89214 Pressure ulcer of right hip, stage 4 160 Yes -- -- No
L89216 Pressure-induced deep tissue damage of right hip 160 Yes No No No
L89219 Pressure ulcer of right hip, unspecified stage 160 Yes No No No
L89220 Pressure ulcer of left hip, unstageable 158 158 158 Yes Yes Yes No
L89220 Pressure ulcer of left hip, unstageable 160 Yes -- -- No
L89221 Pressure ulcer of left hip, stage 1 160 Yes No No No
L89222 Pressure ulcer of left hip, stage 2 159 159 Yes No Yes No
L89222 Pressure ulcer of left hip, stage 2 160 Yes No -- No
L89223 Pressure ulcer of left hip, stage 3 158 158 158 Yes Yes Yes No
L89223 Pressure ulcer of left hip, stage 3 160 Yes -- -- No
L89224 Pressure ulcer of left hip, stage 4 157 157 157 Yes Yes Yes No
L89224 Pressure ulcer of left hip, stage 4 160 Yes -- -- No
L89226 Pressure-induced deep tissue damage of left hip 160 Yes No No No
L89229 Pressure ulcer of left hip, unspecified stage 160 Yes No No No
L89300 Pressure ulcer of unspecified buttock, unstageable 158 158 158 Yes Yes Yes No
L89300 Pressure ulcer of unspecified buttock, unstageable 160 Yes -- -- No
L89301 Pressure ulcer of unspecified buttock, stage 1 160 Yes No No No
L89302 Pressure ulcer of unspecified buttock, stage 2 159 159 Yes No Yes No
L89302 Pressure ulcer of unspecified buttock, stage 2 160 Yes No -- No
L89303 Pressure ulcer of unspecified buttock, stage 3 158 158 158 Yes Yes Yes No
L89303 Pressure ulcer of unspecified buttock, stage 3 160 Yes -- -- No
L89304 Pressure ulcer of unspecified buttock, stage 4 157 157 157 Yes Yes Yes No
L89304 Pressure ulcer of unspecified buttock, stage 4 160 Yes -- -- No
L89306 Pressure-induced deep tissue damage of unspecified buttock 160 Yes No No No
L89309 Pressure ulcer of unspecified buttock, unspecified stage 160 Yes No No No
L89310 Pressure ulcer of right buttock, unstageable 158 158 158 Yes Yes Yes No
L89310 Pressure ulcer of right buttock, unstageable 160 Yes -- -- No
L89311 Pressure ulcer of right buttock, stage 1 160 Yes No No No
L89312 Pressure ulcer of right buttock, stage 2 159 159 Yes No Yes No
L89312 Pressure ulcer of right buttock, stage 2 160 Yes No -- No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 118 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

L89313 Pressure ulcer of right buttock, stage 3 158 158 158 Yes Yes Yes No
L89313 Pressure ulcer of right buttock, stage 3 160 Yes -- -- No
L89314 Pressure ulcer of right buttock, stage 4 157 157 157 Yes Yes Yes No
L89314 Pressure ulcer of right buttock, stage 4 160 Yes -- -- No
L89316 Pressure-induced deep tissue damage of right buttock 160 Yes No No No
L89319 Pressure ulcer of right buttock, unspecified stage 160 Yes No No No
L89320 Pressure ulcer of left buttock, unstageable 158 158 158 Yes Yes Yes No
L89320 Pressure ulcer of left buttock, unstageable 160 Yes -- -- No
L89321 Pressure ulcer of left buttock, stage 1 160 Yes No No No
L89322 Pressure ulcer of left buttock, stage 2 159 159 Yes No Yes No
L89322 Pressure ulcer of left buttock, stage 2 160 Yes No -- No
L89323 Pressure ulcer of left buttock, stage 3 158 158 158 Yes Yes Yes No
L89323 Pressure ulcer of left buttock, stage 3 160 Yes -- -- No
L89324 Pressure ulcer of left buttock, stage 4 157 157 157 Yes Yes Yes No
L89324 Pressure ulcer of left buttock, stage 4 160 Yes -- -- No
L89326 Pressure-induced deep tissue damage of left buttock 160 Yes No No No
L89329 Pressure ulcer of left buttock, unspecified stage 160 Yes No No No
L8940 Pressure ulcer of contiguous site of back, buttock and hip, unspecified stage 160 Yes No No No
L8941 Pressure ulcer of contiguous site of back, buttock and hip, stage 1 160 Yes No No No
L8942 Pressure ulcer of contiguous site of back, buttock and hip, stage 2 159 159 Yes No Yes No
L8942 Pressure ulcer of contiguous site of back, buttock and hip, stage 2 160 Yes No -- No
L8943 Pressure ulcer of contiguous site of back, buttock and hip, stage 3 158 158 158 Yes Yes Yes No
L8943 Pressure ulcer of contiguous site of back, buttock and hip, stage 3 160 Yes -- -- No
L8944 Pressure ulcer of contiguous site of back, buttock and hip, stage 4 157 157 157 Yes Yes Yes No
L8944 Pressure ulcer of contiguous site of back, buttock and hip, stage 4 160 Yes -- -- No
L8945 Pressure ulcer of contiguous site of back, buttock and hip, unstageable 158 158 158 Yes Yes Yes No
L8945 Pressure ulcer of contiguous site of back, buttock and hip, unstageable 160 Yes -- -- No
L8946 Pressure-induced deep tissue damage of contiguous site of back, buttock and hip 160 Yes No No No
L89500 Pressure ulcer of unspecified ankle, unstageable 158 158 158 Yes Yes Yes No
L89500 Pressure ulcer of unspecified ankle, unstageable 160 Yes -- -- No
L89501 Pressure ulcer of unspecified ankle, stage 1 160 Yes No No No
L89502 Pressure ulcer of unspecified ankle, stage 2 159 159 Yes No Yes No
L89502 Pressure ulcer of unspecified ankle, stage 2 160 Yes No -- No
L89503 Pressure ulcer of unspecified ankle, stage 3 158 158 158 Yes Yes Yes No
L89503 Pressure ulcer of unspecified ankle, stage 3 160 Yes -- -- No
L89504 Pressure ulcer of unspecified ankle, stage 4 157 157 157 Yes Yes Yes No
L89504 Pressure ulcer of unspecified ankle, stage 4 160 Yes -- -- No
L89506 Pressure-induced deep tissue damage of unspecified ankle 160 Yes No No No
L89509 Pressure ulcer of unspecified ankle, unspecified stage 160 Yes No No No
L89510 Pressure ulcer of right ankle, unstageable 158 158 158 Yes Yes Yes No
L89510 Pressure ulcer of right ankle, unstageable 160 Yes -- -- No
L89511 Pressure ulcer of right ankle, stage 1 160 Yes No No No
L89512 Pressure ulcer of right ankle, stage 2 159 159 Yes No Yes No
L89512 Pressure ulcer of right ankle, stage 2 160 Yes No -- No
L89513 Pressure ulcer of right ankle, stage 3 158 158 158 Yes Yes Yes No
L89513 Pressure ulcer of right ankle, stage 3 160 Yes -- -- No
L89514 Pressure ulcer of right ankle, stage 4 157 157 157 Yes Yes Yes No
L89514 Pressure ulcer of right ankle, stage 4 160 Yes -- -- No
L89516 Pressure-induced deep tissue damage of right ankle 160 Yes No No No
L89519 Pressure ulcer of right ankle, unspecified stage 160 Yes No No No
L89520 Pressure ulcer of left ankle, unstageable 158 158 158 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 119 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

L89520 Pressure ulcer of left ankle, unstageable 160 Yes -- -- No


L89521 Pressure ulcer of left ankle, stage 1 160 Yes No No No
L89522 Pressure ulcer of left ankle, stage 2 159 159 Yes No Yes No
L89522 Pressure ulcer of left ankle, stage 2 160 Yes No -- No
L89523 Pressure ulcer of left ankle, stage 3 158 158 158 Yes Yes Yes No
L89523 Pressure ulcer of left ankle, stage 3 160 Yes -- -- No
L89524 Pressure ulcer of left ankle, stage 4 157 157 157 Yes Yes Yes No
L89524 Pressure ulcer of left ankle, stage 4 160 Yes -- -- No
L89526 Pressure-induced deep tissue damage of left ankle 160 Yes No No No
L89529 Pressure ulcer of left ankle, unspecified stage 160 Yes No No No
L89600 Pressure ulcer of unspecified heel, unstageable 158 158 158 Yes Yes Yes No
L89600 Pressure ulcer of unspecified heel, unstageable 160 Yes -- -- No
L89601 Pressure ulcer of unspecified heel, stage 1 160 Yes No No No
L89602 Pressure ulcer of unspecified heel, stage 2 159 159 Yes No Yes No
L89602 Pressure ulcer of unspecified heel, stage 2 160 Yes No -- No
L89603 Pressure ulcer of unspecified heel, stage 3 158 158 158 Yes Yes Yes No
L89603 Pressure ulcer of unspecified heel, stage 3 160 Yes -- -- No
L89604 Pressure ulcer of unspecified heel, stage 4 157 157 157 Yes Yes Yes No
L89604 Pressure ulcer of unspecified heel, stage 4 160 Yes -- -- No
L89606 Pressure-induced deep tissue damage of unspecified heel 160 Yes No No No
L89609 Pressure ulcer of unspecified heel, unspecified stage 160 Yes No No No
L89610 Pressure ulcer of right heel, unstageable 158 158 158 Yes Yes Yes No
L89610 Pressure ulcer of right heel, unstageable 160 Yes -- -- No
L89611 Pressure ulcer of right heel, stage 1 160 Yes No No No
L89612 Pressure ulcer of right heel, stage 2 159 159 Yes No Yes No
L89612 Pressure ulcer of right heel, stage 2 160 Yes No -- No
L89613 Pressure ulcer of right heel, stage 3 158 158 158 Yes Yes Yes No
L89613 Pressure ulcer of right heel, stage 3 160 Yes -- -- No
L89614 Pressure ulcer of right heel, stage 4 157 157 157 Yes Yes Yes No
L89614 Pressure ulcer of right heel, stage 4 160 Yes -- -- No
L89616 Pressure-induced deep tissue damage of right heel 160 Yes No No No
L89619 Pressure ulcer of right heel, unspecified stage 160 Yes No No No
L89620 Pressure ulcer of left heel, unstageable 158 158 158 Yes Yes Yes No
L89620 Pressure ulcer of left heel, unstageable 160 Yes -- -- No
L89621 Pressure ulcer of left heel, stage 1 160 Yes No No No
L89622 Pressure ulcer of left heel, stage 2 159 159 Yes No Yes No
L89622 Pressure ulcer of left heel, stage 2 160 Yes No -- No
L89623 Pressure ulcer of left heel, stage 3 158 158 158 Yes Yes Yes No
L89623 Pressure ulcer of left heel, stage 3 160 Yes -- -- No
L89624 Pressure ulcer of left heel, stage 4 157 157 157 Yes Yes Yes No
L89624 Pressure ulcer of left heel, stage 4 160 Yes -- -- No
L89626 Pressure-induced deep tissue damage of left heel 160 Yes No No No
L89629 Pressure ulcer of left heel, unspecified stage 160 Yes No No No
L89810 Pressure ulcer of head, unstageable 158 158 158 Yes Yes Yes No
L89810 Pressure ulcer of head, unstageable 160 Yes -- -- No
L89811 Pressure ulcer of head, stage 1 160 Yes No No No
L89812 Pressure ulcer of head, stage 2 159 159 Yes No Yes No
L89812 Pressure ulcer of head, stage 2 160 Yes No -- No
L89813 Pressure ulcer of head, stage 3 158 158 158 Yes Yes Yes No
L89813 Pressure ulcer of head, stage 3 160 Yes -- -- No
L89814 Pressure ulcer of head, stage 4 157 157 157 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 120 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

L89814 Pressure ulcer of head, stage 4 160 Yes -- -- No


L89816 Pressure-induced deep tissue damage of head 160 Yes No No No
L89819 Pressure ulcer of head, unspecified stage 160 Yes No No No
L89890 Pressure ulcer of other site, unstageable 158 158 158 Yes Yes Yes No
L89890 Pressure ulcer of other site, unstageable 160 Yes -- -- No
L89891 Pressure ulcer of other site, stage 1 160 Yes No No No
L89892 Pressure ulcer of other site, stage 2 159 159 Yes No Yes No
L89892 Pressure ulcer of other site, stage 2 160 Yes No -- No
L89893 Pressure ulcer of other site, stage 3 158 158 158 Yes Yes Yes No
L89893 Pressure ulcer of other site, stage 3 160 Yes -- -- No
L89894 Pressure ulcer of other site, stage 4 157 157 157 Yes Yes Yes No
L89894 Pressure ulcer of other site, stage 4 160 Yes -- -- No
L89896 Pressure-induced deep tissue damage of other site 160 Yes No No No
L89899 Pressure ulcer of other site, unspecified stage 160 Yes No No No
L8990 Pressure ulcer of unspecified site, unspecified stage 160 Yes No No No
L8991 Pressure ulcer of unspecified site, stage 1 160 Yes No No No
L8992 Pressure ulcer of unspecified site, stage 2 159 159 Yes No Yes No
L8992 Pressure ulcer of unspecified site, stage 2 160 Yes No -- No
L8993 Pressure ulcer of unspecified site, stage 3 158 158 158 Yes Yes Yes No
L8993 Pressure ulcer of unspecified site, stage 3 160 Yes -- -- No
L8994 Pressure ulcer of unspecified site, stage 4 157 157 157 Yes Yes Yes No
L8994 Pressure ulcer of unspecified site, stage 4 160 Yes -- -- No
L8995 Pressure ulcer of unspecified site, unstageable 158 158 158 Yes Yes Yes No
L8995 Pressure ulcer of unspecified site, unstageable 160 Yes -- -- No
L8996 Pressure-induced deep tissue damage of unspecified site 160 Yes No No No
L945 Poikiloderma vasculare atrophicans 316 No No No Yes
L97101 Non-pressure chronic ulcer of unspecified thigh limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97102 Non-pressure chronic ulcer of unspecified thigh with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97103 Non-pressure chronic ulcer of unspecified thigh with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97104 Non-pressure chronic ulcer of unspecified thigh with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97105 Non-pressure chronic ulcer of unspecified thigh with muscle involvement without evidence of 161 161 161 311 Yes Yes Yes Yes
necrosis
L97106 Non-pressure chronic ulcer of unspecified thigh with bone involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L97108 Non-pressure chronic ulcer of unspecified thigh with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97109 Non-pressure chronic ulcer of unspecified thigh with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97111 Non-pressure chronic ulcer of right thigh limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97112 Non-pressure chronic ulcer of right thigh with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97113 Non-pressure chronic ulcer of right thigh with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97114 Non-pressure chronic ulcer of right thigh with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97115 Non-pressure chronic ulcer of right thigh with muscle involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L97116 Non-pressure chronic ulcer of right thigh with bone involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L97118 Non-pressure chronic ulcer of right thigh with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97119 Non-pressure chronic ulcer of right thigh with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97121 Non-pressure chronic ulcer of left thigh limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97122 Non-pressure chronic ulcer of left thigh with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97123 Non-pressure chronic ulcer of left thigh with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97124 Non-pressure chronic ulcer of left thigh with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97125 Non-pressure chronic ulcer of left thigh with muscle involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L97126 Non-pressure chronic ulcer of left thigh with bone involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L97128 Non-pressure chronic ulcer of left thigh with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97129 Non-pressure chronic ulcer of left thigh with unspecified severity 161 161 161 311 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 121 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

L97201 Non-pressure chronic ulcer of unspecified calf limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97202 Non-pressure chronic ulcer of unspecified calf with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97203 Non-pressure chronic ulcer of unspecified calf with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97204 Non-pressure chronic ulcer of unspecified calf with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97205 Non-pressure chronic ulcer of unspecified calf with muscle involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L97206 Non-pressure chronic ulcer of unspecified calf with bone involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L97208 Non-pressure chronic ulcer of unspecified calf with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97209 Non-pressure chronic ulcer of unspecified calf with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97211 Non-pressure chronic ulcer of right calf limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97212 Non-pressure chronic ulcer of right calf with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97213 Non-pressure chronic ulcer of right calf with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97214 Non-pressure chronic ulcer of right calf with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97215 Non-pressure chronic ulcer of right calf with muscle involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L97216 Non-pressure chronic ulcer of right calf with bone involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L97218 Non-pressure chronic ulcer of right calf with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97219 Non-pressure chronic ulcer of right calf with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97221 Non-pressure chronic ulcer of left calf limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97222 Non-pressure chronic ulcer of left calf with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97223 Non-pressure chronic ulcer of left calf with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97224 Non-pressure chronic ulcer of left calf with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97225 Non-pressure chronic ulcer of left calf with muscle involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L97226 Non-pressure chronic ulcer of left calf with bone involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L97228 Non-pressure chronic ulcer of left calf with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97229 Non-pressure chronic ulcer of left calf with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97301 Non-pressure chronic ulcer of unspecified ankle limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97302 Non-pressure chronic ulcer of unspecified ankle with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97303 Non-pressure chronic ulcer of unspecified ankle with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97304 Non-pressure chronic ulcer of unspecified ankle with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97305 Non-pressure chronic ulcer of unspecified ankle with muscle involvement without evidence of 161 161 161 311 Yes Yes Yes Yes
necrosis
L97306 Non-pressure chronic ulcer of unspecified ankle with bone involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L97308 Non-pressure chronic ulcer of unspecified ankle with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97309 Non-pressure chronic ulcer of unspecified ankle with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97311 Non-pressure chronic ulcer of right ankle limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97312 Non-pressure chronic ulcer of right ankle with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97313 Non-pressure chronic ulcer of right ankle with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97314 Non-pressure chronic ulcer of right ankle with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97315 Non-pressure chronic ulcer of right ankle with muscle involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L97316 Non-pressure chronic ulcer of right ankle with bone involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L97318 Non-pressure chronic ulcer of right ankle with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97319 Non-pressure chronic ulcer of right ankle with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97321 Non-pressure chronic ulcer of left ankle limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97322 Non-pressure chronic ulcer of left ankle with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97323 Non-pressure chronic ulcer of left ankle with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97324 Non-pressure chronic ulcer of left ankle with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97325 Non-pressure chronic ulcer of left ankle with muscle involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L97326 Non-pressure chronic ulcer of left ankle with bone involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L97328 Non-pressure chronic ulcer of left ankle with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97329 Non-pressure chronic ulcer of left ankle with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97401 Non-pressure chronic ulcer of unspecified heel and midfoot limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97402 Non-pressure chronic ulcer of unspecified heel and midfoot with fat layer exposed 161 161 161 311 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 122 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

L97403 Non-pressure chronic ulcer of unspecified heel and midfoot with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97404 Non-pressure chronic ulcer of unspecified heel and midfoot with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97405 Non-pressure chronic ulcer of unspecified heel and midfoot with muscle involvement without 161 161 161 311 Yes Yes Yes Yes
evidence of necrosis
L97406 Non-pressure chronic ulcer of unspecified heel and midfoot with bone involvement without evidence 161 161 161 311 Yes Yes Yes Yes
of necrosis
L97408 Non-pressure chronic ulcer of unspecified heel and midfoot with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97409 Non-pressure chronic ulcer of unspecified heel and midfoot with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97411 Non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97412 Non-pressure chronic ulcer of right heel and midfoot with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97413 Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97414 Non-pressure chronic ulcer of right heel and midfoot with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97415 Non-pressure chronic ulcer of right heel and midfoot with muscle involvement without evidence of 161 161 161 311 Yes Yes Yes Yes
necrosis
L97416 Non-pressure chronic ulcer of right heel and midfoot with bone involvement without evidence of 161 161 161 311 Yes Yes Yes Yes
necrosis
L97418 Non-pressure chronic ulcer of right heel and midfoot with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97419 Non-pressure chronic ulcer of right heel and midfoot with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97421 Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97422 Non-pressure chronic ulcer of left heel and midfoot with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97423 Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97424 Non-pressure chronic ulcer of left heel and midfoot with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97425 Non-pressure chronic ulcer of left heel and midfoot with muscle involvement without evidence of 161 161 161 311 Yes Yes Yes Yes
necrosis
L97426 Non-pressure chronic ulcer of left heel and midfoot with bone involvement without evidence of 161 161 161 311 Yes Yes Yes Yes
necrosis
L97428 Non-pressure chronic ulcer of left heel and midfoot with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97429 Non-pressure chronic ulcer of left heel and midfoot with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97501 Non-pressure chronic ulcer of other part of unspecified foot limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97502 Non-pressure chronic ulcer of other part of unspecified foot with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97503 Non-pressure chronic ulcer of other part of unspecified foot with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97504 Non-pressure chronic ulcer of other part of unspecified foot with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97505 Non-pressure chronic ulcer of other part of unspecified foot with muscle involvement without 161 161 161 311 Yes Yes Yes Yes
evidence of necrosis
L97506 Non-pressure chronic ulcer of other part of unspecified foot with bone involvement without 161 161 161 311 Yes Yes Yes Yes
evidence of necrosis
L97508 Non-pressure chronic ulcer of other part of unspecified foot with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97509 Non-pressure chronic ulcer of other part of unspecified foot with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97511 Non-pressure chronic ulcer of other part of right foot limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97512 Non-pressure chronic ulcer of other part of right foot with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97513 Non-pressure chronic ulcer of other part of right foot with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97514 Non-pressure chronic ulcer of other part of right foot with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97515 Non-pressure chronic ulcer of other part of right foot with muscle involvement without evidence of 161 161 161 311 Yes Yes Yes Yes
necrosis
L97516 Non-pressure chronic ulcer of other part of right foot with bone involvement without evidence of 161 161 161 311 Yes Yes Yes Yes
necrosis
L97518 Non-pressure chronic ulcer of other part of right foot with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97519 Non-pressure chronic ulcer of other part of right foot with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97521 Non-pressure chronic ulcer of other part of left foot limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97522 Non-pressure chronic ulcer of other part of left foot with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97523 Non-pressure chronic ulcer of other part of left foot with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 123 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

L97524 Non-pressure chronic ulcer of other part of left foot with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97525 Non-pressure chronic ulcer of other part of left foot with muscle involvement without evidence of 161 161 161 311 Yes Yes Yes Yes
necrosis
L97526 Non-pressure chronic ulcer of other part of left foot with bone involvement without evidence of 161 161 161 311 Yes Yes Yes Yes
necrosis
L97528 Non-pressure chronic ulcer of other part of left foot with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97529 Non-pressure chronic ulcer of other part of left foot with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97801 Non-pressure chronic ulcer of other part of unspecified lower leg limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97802 Non-pressure chronic ulcer of other part of unspecified lower leg with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97803 Non-pressure chronic ulcer of other part of unspecified lower leg with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97804 Non-pressure chronic ulcer of other part of unspecified lower leg with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97805 Non-pressure chronic ulcer of other part of unspecified lower leg with muscle involvement without 161 161 161 311 Yes Yes Yes Yes
evidence of necrosis
L97806 Non-pressure chronic ulcer of other part of unspecified lower leg with bone involvement without 161 161 161 311 Yes Yes Yes Yes
evidence of necrosis
L97808 Non-pressure chronic ulcer of other part of unspecified lower leg with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97809 Non-pressure chronic ulcer of other part of unspecified lower leg with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97811 Non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97812 Non-pressure chronic ulcer of other part of right lower leg with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97813 Non-pressure chronic ulcer of other part of right lower leg with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97814 Non-pressure chronic ulcer of other part of right lower leg with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97815 Non-pressure chronic ulcer of other part of right lower leg with muscle involvement without 161 161 161 311 Yes Yes Yes Yes
evidence of necrosis
L97816 Non-pressure chronic ulcer of other part of right lower leg with bone involvement without evidence 161 161 161 311 Yes Yes Yes Yes
of necrosis
L97818 Non-pressure chronic ulcer of other part of right lower leg with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97819 Non-pressure chronic ulcer of other part of right lower leg with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97821 Non-pressure chronic ulcer of other part of left lower leg limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97822 Non-pressure chronic ulcer of other part of left lower leg with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97823 Non-pressure chronic ulcer of other part of left lower leg with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97824 Non-pressure chronic ulcer of other part of left lower leg with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97825 Non-pressure chronic ulcer of other part of left lower leg with muscle involvement without evidence 161 161 161 311 Yes Yes Yes Yes
of necrosis
L97826 Non-pressure chronic ulcer of other part of left lower leg with bone involvement without evidence of 161 161 161 311 Yes Yes Yes Yes
necrosis
L97828 Non-pressure chronic ulcer of other part of left lower leg with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97829 Non-pressure chronic ulcer of other part of left lower leg with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97901 Non-pressure chronic ulcer of unspecified part of unspecified lower leg limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97902 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97903 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97904 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97905 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with muscle involvement 161 161 161 311 Yes Yes Yes Yes
without evidence of necrosis
L97906 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with bone involvement 161 161 161 311 Yes Yes Yes Yes
without evidence of necrosis
L97908 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97909 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97911 Non-pressure chronic ulcer of unspecified part of right lower leg limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97912 Non-pressure chronic ulcer of unspecified part of right lower leg with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97913 Non-pressure chronic ulcer of unspecified part of right lower leg with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97914 Non-pressure chronic ulcer of unspecified part of right lower leg with necrosis of bone 161 161 161 311 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 124 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

L97915 Non-pressure chronic ulcer of unspecified part of right lower leg with muscle involvement without 161 161 161 311 Yes Yes Yes Yes
evidence of necrosis
L97916 Non-pressure chronic ulcer of unspecified part of right lower leg with bone involvement without 161 161 161 311 Yes Yes Yes Yes
evidence of necrosis
L97918 Non-pressure chronic ulcer of unspecified part of right lower leg with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97919 Non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L97921 Non-pressure chronic ulcer of unspecified part of left lower leg limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L97922 Non-pressure chronic ulcer of unspecified part of left lower leg with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L97923 Non-pressure chronic ulcer of unspecified part of left lower leg with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L97924 Non-pressure chronic ulcer of unspecified part of left lower leg with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L97925 Non-pressure chronic ulcer of unspecified part of left lower leg with muscle involvement without 161 161 161 311 Yes Yes Yes Yes
evidence of necrosis
L97926 Non-pressure chronic ulcer of unspecified part of left lower leg with bone involvement without 161 161 161 311 Yes Yes Yes Yes
evidence of necrosis
L97928 Non-pressure chronic ulcer of unspecified part of left lower leg with other specified severity 161 161 161 311 Yes Yes Yes Yes
L97929 Non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L98411 Non-pressure chronic ulcer of buttock limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L98412 Non-pressure chronic ulcer of buttock with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L98413 Non-pressure chronic ulcer of buttock with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L98414 Non-pressure chronic ulcer of buttock with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L98415 Non-pressure chronic ulcer of buttock with muscle involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L98416 Non-pressure chronic ulcer of buttock with bone involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L98418 Non-pressure chronic ulcer of buttock with other specified severity 161 161 161 311 Yes Yes Yes Yes
L98419 Non-pressure chronic ulcer of buttock with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L98421 Non-pressure chronic ulcer of back limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L98422 Non-pressure chronic ulcer of back with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L98423 Non-pressure chronic ulcer of back with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L98424 Non-pressure chronic ulcer of back with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L98425 Non-pressure chronic ulcer of back with muscle involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L98426 Non-pressure chronic ulcer of back with bone involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L98428 Non-pressure chronic ulcer of back with other specified severity 161 161 161 311 Yes Yes Yes Yes
L98429 Non-pressure chronic ulcer of back with unspecified severity 161 161 161 311 Yes Yes Yes Yes
L98491 Non-pressure chronic ulcer of skin of other sites limited to breakdown of skin 161 161 161 311 Yes Yes Yes Yes
L98492 Non-pressure chronic ulcer of skin of other sites with fat layer exposed 161 161 161 311 Yes Yes Yes Yes
L98493 Non-pressure chronic ulcer of skin of other sites with necrosis of muscle 161 161 161 311 Yes Yes Yes Yes
L98494 Non-pressure chronic ulcer of skin of other sites with necrosis of bone 161 161 161 311 Yes Yes Yes Yes
L98495 Non-pressure chronic ulcer of skin of other sites with muscle involvement without evidence of 161 161 161 311 Yes Yes Yes Yes
necrosis
L98496 Non-pressure chronic ulcer of skin of other sites with bone involvement without evidence of necrosis 161 161 161 311 Yes Yes Yes Yes
L98498 Non-pressure chronic ulcer of skin of other sites with other specified severity 161 161 161 311 Yes Yes Yes Yes
L98499 Non-pressure chronic ulcer of skin of other sites with unspecified severity 161 161 161 311 Yes Yes Yes Yes
M0000 Staphylococcal arthritis, unspecified joint 39 39 39 Yes Yes Yes No
M00011 Staphylococcal arthritis, right shoulder 39 39 39 Yes Yes Yes No
M00012 Staphylococcal arthritis, left shoulder 39 39 39 Yes Yes Yes No
M00019 Staphylococcal arthritis, unspecified shoulder 39 39 39 Yes Yes Yes No
M00021 Staphylococcal arthritis, right elbow 39 39 39 Yes Yes Yes No
M00022 Staphylococcal arthritis, left elbow 39 39 39 Yes Yes Yes No
M00029 Staphylococcal arthritis, unspecified elbow 39 39 39 Yes Yes Yes No
M00031 Staphylococcal arthritis, right wrist 39 39 39 Yes Yes Yes No
M00032 Staphylococcal arthritis, left wrist 39 39 39 Yes Yes Yes No
M00039 Staphylococcal arthritis, unspecified wrist 39 39 39 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 125 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M00041 Staphylococcal arthritis, right hand 39 39 39 Yes Yes Yes No


M00042 Staphylococcal arthritis, left hand 39 39 39 Yes Yes Yes No
M00049 Staphylococcal arthritis, unspecified hand 39 39 39 Yes Yes Yes No
M00051 Staphylococcal arthritis, right hip 39 39 39 Yes Yes Yes No
M00052 Staphylococcal arthritis, left hip 39 39 39 Yes Yes Yes No
M00059 Staphylococcal arthritis, unspecified hip 39 39 39 Yes Yes Yes No
M00061 Staphylococcal arthritis, right knee 39 39 39 Yes Yes Yes No
M00062 Staphylococcal arthritis, left knee 39 39 39 Yes Yes Yes No
M00069 Staphylococcal arthritis, unspecified knee 39 39 39 Yes Yes Yes No
M00071 Staphylococcal arthritis, right ankle and foot 39 39 39 Yes Yes Yes No
M00072 Staphylococcal arthritis, left ankle and foot 39 39 39 Yes Yes Yes No
M00079 Staphylococcal arthritis, unspecified ankle and foot 39 39 39 Yes Yes Yes No
M0008 Staphylococcal arthritis, vertebrae 39 39 39 Yes Yes Yes No
M0009 Staphylococcal polyarthritis 39 39 39 Yes Yes Yes No
M0010 Pneumococcal arthritis, unspecified joint 39 39 39 Yes Yes Yes No
M00111 Pneumococcal arthritis, right shoulder 39 39 39 Yes Yes Yes No
M00112 Pneumococcal arthritis, left shoulder 39 39 39 Yes Yes Yes No
M00119 Pneumococcal arthritis, unspecified shoulder 39 39 39 Yes Yes Yes No
M00121 Pneumococcal arthritis, right elbow 39 39 39 Yes Yes Yes No
M00122 Pneumococcal arthritis, left elbow 39 39 39 Yes Yes Yes No
M00129 Pneumococcal arthritis, unspecified elbow 39 39 39 Yes Yes Yes No
M00131 Pneumococcal arthritis, right wrist 39 39 39 Yes Yes Yes No
M00132 Pneumococcal arthritis, left wrist 39 39 39 Yes Yes Yes No
M00139 Pneumococcal arthritis, unspecified wrist 39 39 39 Yes Yes Yes No
M00141 Pneumococcal arthritis, right hand 39 39 39 Yes Yes Yes No
M00142 Pneumococcal arthritis, left hand 39 39 39 Yes Yes Yes No
M00149 Pneumococcal arthritis, unspecified hand 39 39 39 Yes Yes Yes No
M00151 Pneumococcal arthritis, right hip 39 39 39 Yes Yes Yes No
M00152 Pneumococcal arthritis, left hip 39 39 39 Yes Yes Yes No
M00159 Pneumococcal arthritis, unspecified hip 39 39 39 Yes Yes Yes No
M00161 Pneumococcal arthritis, right knee 39 39 39 Yes Yes Yes No
M00162 Pneumococcal arthritis, left knee 39 39 39 Yes Yes Yes No
M00169 Pneumococcal arthritis, unspecified knee 39 39 39 Yes Yes Yes No
M00171 Pneumococcal arthritis, right ankle and foot 39 39 39 Yes Yes Yes No
M00172 Pneumococcal arthritis, left ankle and foot 39 39 39 Yes Yes Yes No
M00179 Pneumococcal arthritis, unspecified ankle and foot 39 39 39 Yes Yes Yes No
M0018 Pneumococcal arthritis, vertebrae 39 39 39 Yes Yes Yes No
M0019 Pneumococcal polyarthritis 39 39 39 Yes Yes Yes No
M0020 Other streptococcal arthritis, unspecified joint 39 39 39 Yes Yes Yes No
M00211 Other streptococcal arthritis, right shoulder 39 39 39 Yes Yes Yes No
M00212 Other streptococcal arthritis, left shoulder 39 39 39 Yes Yes Yes No
M00219 Other streptococcal arthritis, unspecified shoulder 39 39 39 Yes Yes Yes No
M00221 Other streptococcal arthritis, right elbow 39 39 39 Yes Yes Yes No
M00222 Other streptococcal arthritis, left elbow 39 39 39 Yes Yes Yes No
M00229 Other streptococcal arthritis, unspecified elbow 39 39 39 Yes Yes Yes No
M00231 Other streptococcal arthritis, right wrist 39 39 39 Yes Yes Yes No
M00232 Other streptococcal arthritis, left wrist 39 39 39 Yes Yes Yes No
M00239 Other streptococcal arthritis, unspecified wrist 39 39 39 Yes Yes Yes No
M00241 Other streptococcal arthritis, right hand 39 39 39 Yes Yes Yes No
M00242 Other streptococcal arthritis, left hand 39 39 39 Yes Yes Yes No
M00249 Other streptococcal arthritis, unspecified hand 39 39 39 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 126 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M00251 Other streptococcal arthritis, right hip 39 39 39 Yes Yes Yes No


M00252 Other streptococcal arthritis, left hip 39 39 39 Yes Yes Yes No
M00259 Other streptococcal arthritis, unspecified hip 39 39 39 Yes Yes Yes No
M00261 Other streptococcal arthritis, right knee 39 39 39 Yes Yes Yes No
M00262 Other streptococcal arthritis, left knee 39 39 39 Yes Yes Yes No
M00269 Other streptococcal arthritis, unspecified knee 39 39 39 Yes Yes Yes No
M00271 Other streptococcal arthritis, right ankle and foot 39 39 39 Yes Yes Yes No
M00272 Other streptococcal arthritis, left ankle and foot 39 39 39 Yes Yes Yes No
M00279 Other streptococcal arthritis, unspecified ankle and foot 39 39 39 Yes Yes Yes No
M0028 Other streptococcal arthritis, vertebrae 39 39 39 Yes Yes Yes No
M0029 Other streptococcal polyarthritis 39 39 39 Yes Yes Yes No
M0080 Arthritis due to other bacteria, unspecified joint 39 39 39 Yes Yes Yes No
M00811 Arthritis due to other bacteria, right shoulder 39 39 39 Yes Yes Yes No
M00812 Arthritis due to other bacteria, left shoulder 39 39 39 Yes Yes Yes No
M00819 Arthritis due to other bacteria, unspecified shoulder 39 39 39 Yes Yes Yes No
M00821 Arthritis due to other bacteria, right elbow 39 39 39 Yes Yes Yes No
M00822 Arthritis due to other bacteria, left elbow 39 39 39 Yes Yes Yes No
M00829 Arthritis due to other bacteria, unspecified elbow 39 39 39 Yes Yes Yes No
M00831 Arthritis due to other bacteria, right wrist 39 39 39 Yes Yes Yes No
M00832 Arthritis due to other bacteria, left wrist 39 39 39 Yes Yes Yes No
M00839 Arthritis due to other bacteria, unspecified wrist 39 39 39 Yes Yes Yes No
M00841 Arthritis due to other bacteria, right hand 39 39 39 Yes Yes Yes No
M00842 Arthritis due to other bacteria, left hand 39 39 39 Yes Yes Yes No
M00849 Arthritis due to other bacteria, unspecified hand 39 39 39 Yes Yes Yes No
M00851 Arthritis due to other bacteria, right hip 39 39 39 Yes Yes Yes No
M00852 Arthritis due to other bacteria, left hip 39 39 39 Yes Yes Yes No
M00859 Arthritis due to other bacteria, unspecified hip 39 39 39 Yes Yes Yes No
M00861 Arthritis due to other bacteria, right knee 39 39 39 Yes Yes Yes No
M00862 Arthritis due to other bacteria, left knee 39 39 39 Yes Yes Yes No
M00869 Arthritis due to other bacteria, unspecified knee 39 39 39 Yes Yes Yes No
M00871 Arthritis due to other bacteria, right ankle and foot 39 39 39 Yes Yes Yes No
M00872 Arthritis due to other bacteria, left ankle and foot 39 39 39 Yes Yes Yes No
M00879 Arthritis due to other bacteria, unspecified ankle and foot 39 39 39 Yes Yes Yes No
M0088 Arthritis due to other bacteria, vertebrae 39 39 39 Yes Yes Yes No
M0089 Polyarthritis due to other bacteria 39 39 39 Yes Yes Yes No
M009 Pyogenic arthritis, unspecified 39 39 39 Yes Yes Yes No
M01X0 Direct infection of unspecified joint in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X11 Direct infection of right shoulder in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X12 Direct infection of left shoulder in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X19 Direct infection of unspecified shoulder in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X21 Direct infection of right elbow in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X22 Direct infection of left elbow in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X29 Direct infection of unspecified elbow in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X31 Direct infection of right wrist in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X32 Direct infection of left wrist in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X39 Direct infection of unspecified wrist in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X41 Direct infection of right hand in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X42 Direct infection of left hand in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X49 Direct infection of unspecified hand in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X51 Direct infection of right hip in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X52 Direct infection of left hip in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 127 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M01X59 Direct infection of unspecified hip in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X61 Direct infection of right knee in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X62 Direct infection of left knee in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X69 Direct infection of unspecified knee in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X71 Direct infection of right ankle and foot in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X72 Direct infection of left ankle and foot in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X79 Direct infection of unspecified ankle and foot in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X8 Direct infection of vertebrae in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M01X9 Direct infection of multiple joints in infectious and parasitic diseases classified elsewhere 39 39 39 Yes Yes Yes No
M0210 Postdysenteric arthropathy, unspecified site 39 39 39 Yes Yes Yes No
M02111 Postdysenteric arthropathy, right shoulder 39 39 39 Yes Yes Yes No
M02112 Postdysenteric arthropathy, left shoulder 39 39 39 Yes Yes Yes No
M02119 Postdysenteric arthropathy, unspecified shoulder 39 39 39 Yes Yes Yes No
M02121 Postdysenteric arthropathy, right elbow 39 39 39 Yes Yes Yes No
M02122 Postdysenteric arthropathy, left elbow 39 39 39 Yes Yes Yes No
M02129 Postdysenteric arthropathy, unspecified elbow 39 39 39 Yes Yes Yes No
M02131 Postdysenteric arthropathy, right wrist 39 39 39 Yes Yes Yes No
M02132 Postdysenteric arthropathy, left wrist 39 39 39 Yes Yes Yes No
M02139 Postdysenteric arthropathy, unspecified wrist 39 39 39 Yes Yes Yes No
M02141 Postdysenteric arthropathy, right hand 39 39 39 Yes Yes Yes No
M02142 Postdysenteric arthropathy, left hand 39 39 39 Yes Yes Yes No
M02149 Postdysenteric arthropathy, unspecified hand 39 39 39 Yes Yes Yes No
M02151 Postdysenteric arthropathy, right hip 39 39 39 Yes Yes Yes No
M02152 Postdysenteric arthropathy, left hip 39 39 39 Yes Yes Yes No
M02159 Postdysenteric arthropathy, unspecified hip 39 39 39 Yes Yes Yes No
M02161 Postdysenteric arthropathy, right knee 39 39 39 Yes Yes Yes No
M02162 Postdysenteric arthropathy, left knee 39 39 39 Yes Yes Yes No
M02169 Postdysenteric arthropathy, unspecified knee 39 39 39 Yes Yes Yes No
M02171 Postdysenteric arthropathy, right ankle and foot 39 39 39 Yes Yes Yes No
M02172 Postdysenteric arthropathy, left ankle and foot 39 39 39 Yes Yes Yes No
M02179 Postdysenteric arthropathy, unspecified ankle and foot 39 39 39 Yes Yes Yes No
M0218 Postdysenteric arthropathy, vertebrae 39 39 39 Yes Yes Yes No
M0219 Postdysenteric arthropathy, multiple sites 39 39 39 Yes Yes Yes No
M0230 Reiter's disease, unspecified site 40 40 40 83 Yes Yes Yes Yes
M02311 Reiter's disease, right shoulder 40 40 40 83 Yes Yes Yes Yes
M02312 Reiter's disease, left shoulder 40 40 40 83 Yes Yes Yes Yes
M02319 Reiter's disease, unspecified shoulder 40 40 40 83 Yes Yes Yes Yes
M02321 Reiter's disease, right elbow 40 40 40 83 Yes Yes Yes Yes
M02322 Reiter's disease, left elbow 40 40 40 83 Yes Yes Yes Yes
M02329 Reiter's disease, unspecified elbow 40 40 40 83 Yes Yes Yes Yes
M02331 Reiter's disease, right wrist 40 40 40 83 Yes Yes Yes Yes
M02332 Reiter's disease, left wrist 40 40 40 83 Yes Yes Yes Yes
M02339 Reiter's disease, unspecified wrist 40 40 40 83 Yes Yes Yes Yes
M02341 Reiter's disease, right hand 40 40 40 83 Yes Yes Yes Yes
M02342 Reiter's disease, left hand 40 40 40 83 Yes Yes Yes Yes
M02349 Reiter's disease, unspecified hand 40 40 40 83 Yes Yes Yes Yes
M02351 Reiter's disease, right hip 40 40 40 83 Yes Yes Yes Yes
M02352 Reiter's disease, left hip 40 40 40 83 Yes Yes Yes Yes
M02359 Reiter's disease, unspecified hip 40 40 40 83 Yes Yes Yes Yes
M02361 Reiter's disease, right knee 40 40 40 83 Yes Yes Yes Yes
M02362 Reiter's disease, left knee 40 40 40 83 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 128 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M02369 Reiter's disease, unspecified knee 40 40 40 83 Yes Yes Yes Yes


M02371 Reiter's disease, right ankle and foot 40 40 40 83 Yes Yes Yes Yes
M02372 Reiter's disease, left ankle and foot 40 40 40 83 Yes Yes Yes Yes
M02379 Reiter's disease, unspecified ankle and foot 40 40 40 83 Yes Yes Yes Yes
M0238 Reiter's disease, vertebrae 40 40 40 83 Yes Yes Yes Yes
M0239 Reiter's disease, multiple sites 40 40 40 83 Yes Yes Yes Yes
M0280 Other reactive arthropathies, unspecified site 39 39 39 Yes Yes Yes No
M02811 Other reactive arthropathies, right shoulder 39 39 39 Yes Yes Yes No
M02812 Other reactive arthropathies, left shoulder 39 39 39 Yes Yes Yes No
M02819 Other reactive arthropathies, unspecified shoulder 39 39 39 Yes Yes Yes No
M02821 Other reactive arthropathies, right elbow 39 39 39 Yes Yes Yes No
M02822 Other reactive arthropathies, left elbow 39 39 39 Yes Yes Yes No
M02829 Other reactive arthropathies, unspecified elbow 39 39 39 Yes Yes Yes No
M02831 Other reactive arthropathies, right wrist 39 39 39 Yes Yes Yes No
M02832 Other reactive arthropathies, left wrist 39 39 39 Yes Yes Yes No
M02839 Other reactive arthropathies, unspecified wrist 39 39 39 Yes Yes Yes No
M02841 Other reactive arthropathies, right hand 39 39 39 Yes Yes Yes No
M02842 Other reactive arthropathies, left hand 39 39 39 Yes Yes Yes No
M02849 Other reactive arthropathies, unspecified hand 39 39 39 Yes Yes Yes No
M02851 Other reactive arthropathies, right hip 39 39 39 Yes Yes Yes No
M02852 Other reactive arthropathies, left hip 39 39 39 Yes Yes Yes No
M02859 Other reactive arthropathies, unspecified hip 39 39 39 Yes Yes Yes No
M02861 Other reactive arthropathies, right knee 39 39 39 Yes Yes Yes No
M02862 Other reactive arthropathies, left knee 39 39 39 Yes Yes Yes No
M02869 Other reactive arthropathies, unspecified knee 39 39 39 Yes Yes Yes No
M02871 Other reactive arthropathies, right ankle and foot 39 39 39 Yes Yes Yes No
M02872 Other reactive arthropathies, left ankle and foot 39 39 39 Yes Yes Yes No
M02879 Other reactive arthropathies, unspecified ankle and foot 39 39 39 Yes Yes Yes No
M0288 Other reactive arthropathies, vertebrae 39 39 39 Yes Yes Yes No
M0289 Other reactive arthropathies, multiple sites 39 39 39 Yes Yes Yes No
M029 Reactive arthropathy, unspecified 39 39 39 Yes Yes Yes No
M041 Periodic fever syndromes 40 40 40 83 Yes Yes Yes Yes
M042 Cryopyrin-associated periodic syndromes 40 40 40 83 Yes Yes Yes Yes
M048 Other autoinflammatory syndromes 40 40 40 83 Yes Yes Yes Yes
M049 Autoinflammatory syndrome, unspecified 40 40 40 83 Yes Yes Yes Yes
M0500 Felty's syndrome, unspecified site 40 40 40 83 Yes Yes Yes Yes
M05011 Felty's syndrome, right shoulder 40 40 40 83 Yes Yes Yes Yes
M05012 Felty's syndrome, left shoulder 40 40 40 83 Yes Yes Yes Yes
M05019 Felty's syndrome, unspecified shoulder 40 40 40 83 Yes Yes Yes Yes
M05021 Felty's syndrome, right elbow 40 40 40 83 Yes Yes Yes Yes
M05022 Felty's syndrome, left elbow 40 40 40 83 Yes Yes Yes Yes
M05029 Felty's syndrome, unspecified elbow 40 40 40 83 Yes Yes Yes Yes
M05031 Felty's syndrome, right wrist 40 40 40 83 Yes Yes Yes Yes
M05032 Felty's syndrome, left wrist 40 40 40 83 Yes Yes Yes Yes
M05039 Felty's syndrome, unspecified wrist 40 40 40 83 Yes Yes Yes Yes
M05041 Felty's syndrome, right hand 40 40 40 83 Yes Yes Yes Yes
M05042 Felty's syndrome, left hand 40 40 40 83 Yes Yes Yes Yes
M05049 Felty's syndrome, unspecified hand 40 40 40 83 Yes Yes Yes Yes
M05051 Felty's syndrome, right hip 40 40 40 83 Yes Yes Yes Yes
M05052 Felty's syndrome, left hip 40 40 40 83 Yes Yes Yes Yes
M05059 Felty's syndrome, unspecified hip 40 40 40 83 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 129 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M05061 Felty's syndrome, right knee 40 40 40 83 Yes Yes Yes Yes


M05062 Felty's syndrome, left knee 40 40 40 83 Yes Yes Yes Yes
M05069 Felty's syndrome, unspecified knee 40 40 40 83 Yes Yes Yes Yes
M05071 Felty's syndrome, right ankle and foot 40 40 40 83 Yes Yes Yes Yes
M05072 Felty's syndrome, left ankle and foot 40 40 40 83 Yes Yes Yes Yes
M05079 Felty's syndrome, unspecified ankle and foot 40 40 40 83 Yes Yes Yes Yes
M0509 Felty's syndrome, multiple sites 40 40 40 83 Yes Yes Yes Yes
M0510 Rheumatoid lung disease with rheumatoid arthritis of unspecified site 40 40 40 83 Yes Yes Yes Yes
M05111 Rheumatoid lung disease with rheumatoid arthritis of right shoulder 40 40 40 83 Yes Yes Yes Yes
M05112 Rheumatoid lung disease with rheumatoid arthritis of left shoulder 40 40 40 83 Yes Yes Yes Yes
M05119 Rheumatoid lung disease with rheumatoid arthritis of unspecified shoulder 40 40 40 83 Yes Yes Yes Yes
M05121 Rheumatoid lung disease with rheumatoid arthritis of right elbow 40 40 40 83 Yes Yes Yes Yes
M05122 Rheumatoid lung disease with rheumatoid arthritis of left elbow 40 40 40 83 Yes Yes Yes Yes
M05129 Rheumatoid lung disease with rheumatoid arthritis of unspecified elbow 40 40 40 83 Yes Yes Yes Yes
M05131 Rheumatoid lung disease with rheumatoid arthritis of right wrist 40 40 40 83 Yes Yes Yes Yes
M05132 Rheumatoid lung disease with rheumatoid arthritis of left wrist 40 40 40 83 Yes Yes Yes Yes
M05139 Rheumatoid lung disease with rheumatoid arthritis of unspecified wrist 40 40 40 83 Yes Yes Yes Yes
M05141 Rheumatoid lung disease with rheumatoid arthritis of right hand 40 40 40 83 Yes Yes Yes Yes
M05142 Rheumatoid lung disease with rheumatoid arthritis of left hand 40 40 40 83 Yes Yes Yes Yes
M05149 Rheumatoid lung disease with rheumatoid arthritis of unspecified hand 40 40 40 83 Yes Yes Yes Yes
M05151 Rheumatoid lung disease with rheumatoid arthritis of right hip 40 40 40 83 Yes Yes Yes Yes
M05152 Rheumatoid lung disease with rheumatoid arthritis of left hip 40 40 40 83 Yes Yes Yes Yes
M05159 Rheumatoid lung disease with rheumatoid arthritis of unspecified hip 40 40 40 83 Yes Yes Yes Yes
M05161 Rheumatoid lung disease with rheumatoid arthritis of right knee 40 40 40 83 Yes Yes Yes Yes
M05162 Rheumatoid lung disease with rheumatoid arthritis of left knee 40 40 40 83 Yes Yes Yes Yes
M05169 Rheumatoid lung disease with rheumatoid arthritis of unspecified knee 40 40 40 83 Yes Yes Yes Yes
M05171 Rheumatoid lung disease with rheumatoid arthritis of right ankle and foot 40 40 40 83 Yes Yes Yes Yes
M05172 Rheumatoid lung disease with rheumatoid arthritis of left ankle and foot 40 40 40 83 Yes Yes Yes Yes
M05179 Rheumatoid lung disease with rheumatoid arthritis of unspecified ankle and foot 40 40 40 83 Yes Yes Yes Yes
M0519 Rheumatoid lung disease with rheumatoid arthritis of multiple sites 40 40 40 83 Yes Yes Yes Yes
M0520 Rheumatoid vasculitis with rheumatoid arthritis of unspecified site 40 40 40 83 Yes Yes Yes Yes
M05211 Rheumatoid vasculitis with rheumatoid arthritis of right shoulder 40 40 40 83 Yes Yes Yes Yes
M05212 Rheumatoid vasculitis with rheumatoid arthritis of left shoulder 40 40 40 83 Yes Yes Yes Yes
M05219 Rheumatoid vasculitis with rheumatoid arthritis of unspecified shoulder 40 40 40 83 Yes Yes Yes Yes
M05221 Rheumatoid vasculitis with rheumatoid arthritis of right elbow 40 40 40 83 Yes Yes Yes Yes
M05222 Rheumatoid vasculitis with rheumatoid arthritis of left elbow 40 40 40 83 Yes Yes Yes Yes
M05229 Rheumatoid vasculitis with rheumatoid arthritis of unspecified elbow 40 40 40 83 Yes Yes Yes Yes
M05231 Rheumatoid vasculitis with rheumatoid arthritis of right wrist 40 40 40 83 Yes Yes Yes Yes
M05232 Rheumatoid vasculitis with rheumatoid arthritis of left wrist 40 40 40 83 Yes Yes Yes Yes
M05239 Rheumatoid vasculitis with rheumatoid arthritis of unspecified wrist 40 40 40 83 Yes Yes Yes Yes
M05241 Rheumatoid vasculitis with rheumatoid arthritis of right hand 40 40 40 83 Yes Yes Yes Yes
M05242 Rheumatoid vasculitis with rheumatoid arthritis of left hand 40 40 40 83 Yes Yes Yes Yes
M05249 Rheumatoid vasculitis with rheumatoid arthritis of unspecified hand 40 40 40 83 Yes Yes Yes Yes
M05251 Rheumatoid vasculitis with rheumatoid arthritis of right hip 40 40 40 83 Yes Yes Yes Yes
M05252 Rheumatoid vasculitis with rheumatoid arthritis of left hip 40 40 40 83 Yes Yes Yes Yes
M05259 Rheumatoid vasculitis with rheumatoid arthritis of unspecified hip 40 40 40 83 Yes Yes Yes Yes
M05261 Rheumatoid vasculitis with rheumatoid arthritis of right knee 40 40 40 83 Yes Yes Yes Yes
M05262 Rheumatoid vasculitis with rheumatoid arthritis of left knee 40 40 40 83 Yes Yes Yes Yes
M05269 Rheumatoid vasculitis with rheumatoid arthritis of unspecified knee 40 40 40 83 Yes Yes Yes Yes
M05271 Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot 40 40 40 83 Yes Yes Yes Yes
M05272 Rheumatoid vasculitis with rheumatoid arthritis of left ankle and foot 40 40 40 83 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 130 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M05279 Rheumatoid vasculitis with rheumatoid arthritis of unspecified ankle and foot 40 40 40 83 Yes Yes Yes Yes
M0529 Rheumatoid vasculitis with rheumatoid arthritis of multiple sites 40 40 40 83 Yes Yes Yes Yes
M0530 Rheumatoid heart disease with rheumatoid arthritis of unspecified site 40 40 40 83 Yes Yes Yes Yes
M05311 Rheumatoid heart disease with rheumatoid arthritis of right shoulder 40 40 40 83 Yes Yes Yes Yes
M05312 Rheumatoid heart disease with rheumatoid arthritis of left shoulder 40 40 40 83 Yes Yes Yes Yes
M05319 Rheumatoid heart disease with rheumatoid arthritis of unspecified shoulder 40 40 40 83 Yes Yes Yes Yes
M05321 Rheumatoid heart disease with rheumatoid arthritis of right elbow 40 40 40 83 Yes Yes Yes Yes
M05322 Rheumatoid heart disease with rheumatoid arthritis of left elbow 40 40 40 83 Yes Yes Yes Yes
M05329 Rheumatoid heart disease with rheumatoid arthritis of unspecified elbow 40 40 40 83 Yes Yes Yes Yes
M05331 Rheumatoid heart disease with rheumatoid arthritis of right wrist 40 40 40 83 Yes Yes Yes Yes
M05332 Rheumatoid heart disease with rheumatoid arthritis of left wrist 40 40 40 83 Yes Yes Yes Yes
M05339 Rheumatoid heart disease with rheumatoid arthritis of unspecified wrist 40 40 40 83 Yes Yes Yes Yes
M05341 Rheumatoid heart disease with rheumatoid arthritis of right hand 40 40 40 83 Yes Yes Yes Yes
M05342 Rheumatoid heart disease with rheumatoid arthritis of left hand 40 40 40 83 Yes Yes Yes Yes
M05349 Rheumatoid heart disease with rheumatoid arthritis of unspecified hand 40 40 40 83 Yes Yes Yes Yes
M05351 Rheumatoid heart disease with rheumatoid arthritis of right hip 40 40 40 83 Yes Yes Yes Yes
M05352 Rheumatoid heart disease with rheumatoid arthritis of left hip 40 40 40 83 Yes Yes Yes Yes
M05359 Rheumatoid heart disease with rheumatoid arthritis of unspecified hip 40 40 40 83 Yes Yes Yes Yes
M05361 Rheumatoid heart disease with rheumatoid arthritis of right knee 40 40 40 83 Yes Yes Yes Yes
M05362 Rheumatoid heart disease with rheumatoid arthritis of left knee 40 40 40 83 Yes Yes Yes Yes
M05369 Rheumatoid heart disease with rheumatoid arthritis of unspecified knee 40 40 40 83 Yes Yes Yes Yes
M05371 Rheumatoid heart disease with rheumatoid arthritis of right ankle and foot 40 40 40 83 Yes Yes Yes Yes
M05372 Rheumatoid heart disease with rheumatoid arthritis of left ankle and foot 40 40 40 83 Yes Yes Yes Yes
M05379 Rheumatoid heart disease with rheumatoid arthritis of unspecified ankle and foot 40 40 40 83 Yes Yes Yes Yes
M0539 Rheumatoid heart disease with rheumatoid arthritis of multiple sites 40 40 40 83 Yes Yes Yes Yes
M0540 Rheumatoid myopathy with rheumatoid arthritis of unspecified site 40 40 40 83 Yes Yes Yes Yes
M0540 Rheumatoid myopathy with rheumatoid arthritis of unspecified site 75 Yes -- -- --
M05411 Rheumatoid myopathy with rheumatoid arthritis of right shoulder 40 40 40 83 Yes Yes Yes Yes
M05411 Rheumatoid myopathy with rheumatoid arthritis of right shoulder 75 Yes -- -- --
M05412 Rheumatoid myopathy with rheumatoid arthritis of left shoulder 40 40 40 83 Yes Yes Yes Yes
M05412 Rheumatoid myopathy with rheumatoid arthritis of left shoulder 75 Yes -- -- --
M05419 Rheumatoid myopathy with rheumatoid arthritis of unspecified shoulder 40 40 40 83 Yes Yes Yes Yes
M05419 Rheumatoid myopathy with rheumatoid arthritis of unspecified shoulder 75 Yes -- -- --
M05421 Rheumatoid myopathy with rheumatoid arthritis of right elbow 40 40 40 83 Yes Yes Yes Yes
M05421 Rheumatoid myopathy with rheumatoid arthritis of right elbow 75 Yes -- -- --
M05422 Rheumatoid myopathy with rheumatoid arthritis of left elbow 40 40 40 83 Yes Yes Yes Yes
M05422 Rheumatoid myopathy with rheumatoid arthritis of left elbow 75 Yes -- -- --
M05429 Rheumatoid myopathy with rheumatoid arthritis of unspecified elbow 40 40 40 83 Yes Yes Yes Yes
M05429 Rheumatoid myopathy with rheumatoid arthritis of unspecified elbow 75 Yes -- -- --
M05431 Rheumatoid myopathy with rheumatoid arthritis of right wrist 40 40 40 83 Yes Yes Yes Yes
M05431 Rheumatoid myopathy with rheumatoid arthritis of right wrist 75 Yes -- -- --
M05432 Rheumatoid myopathy with rheumatoid arthritis of left wrist 40 40 40 83 Yes Yes Yes Yes
M05432 Rheumatoid myopathy with rheumatoid arthritis of left wrist 75 Yes -- -- --
M05439 Rheumatoid myopathy with rheumatoid arthritis of unspecified wrist 40 40 40 83 Yes Yes Yes Yes
M05439 Rheumatoid myopathy with rheumatoid arthritis of unspecified wrist 75 Yes -- -- --
M05441 Rheumatoid myopathy with rheumatoid arthritis of right hand 40 40 40 83 Yes Yes Yes Yes
M05441 Rheumatoid myopathy with rheumatoid arthritis of right hand 75 Yes -- -- --
M05442 Rheumatoid myopathy with rheumatoid arthritis of left hand 40 40 40 83 Yes Yes Yes Yes
M05442 Rheumatoid myopathy with rheumatoid arthritis of left hand 75 Yes -- -- --
M05449 Rheumatoid myopathy with rheumatoid arthritis of unspecified hand 40 40 40 83 Yes Yes Yes Yes
M05449 Rheumatoid myopathy with rheumatoid arthritis of unspecified hand 75 Yes -- -- --

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 131 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M05451 Rheumatoid myopathy with rheumatoid arthritis of right hip 40 40 40 83 Yes Yes Yes Yes
M05451 Rheumatoid myopathy with rheumatoid arthritis of right hip 75 Yes -- -- --
M05452 Rheumatoid myopathy with rheumatoid arthritis of left hip 40 40 40 83 Yes Yes Yes Yes
M05452 Rheumatoid myopathy with rheumatoid arthritis of left hip 75 Yes -- -- --
M05459 Rheumatoid myopathy with rheumatoid arthritis of unspecified hip 40 40 40 83 Yes Yes Yes Yes
M05459 Rheumatoid myopathy with rheumatoid arthritis of unspecified hip 75 Yes -- -- --
M05461 Rheumatoid myopathy with rheumatoid arthritis of right knee 40 40 40 83 Yes Yes Yes Yes
M05461 Rheumatoid myopathy with rheumatoid arthritis of right knee 75 Yes -- -- --
M05462 Rheumatoid myopathy with rheumatoid arthritis of left knee 40 40 40 83 Yes Yes Yes Yes
M05462 Rheumatoid myopathy with rheumatoid arthritis of left knee 75 Yes -- -- --
M05469 Rheumatoid myopathy with rheumatoid arthritis of unspecified knee 40 40 40 83 Yes Yes Yes Yes
M05469 Rheumatoid myopathy with rheumatoid arthritis of unspecified knee 75 Yes -- -- --
M05471 Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot 40 40 40 83 Yes Yes Yes Yes
M05471 Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot 75 Yes -- -- --
M05472 Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot 40 40 40 83 Yes Yes Yes Yes
M05472 Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot 75 Yes -- -- --
M05479 Rheumatoid myopathy with rheumatoid arthritis of unspecified ankle and foot 40 40 40 83 Yes Yes Yes Yes
M05479 Rheumatoid myopathy with rheumatoid arthritis of unspecified ankle and foot 75 Yes -- -- --
M0549 Rheumatoid myopathy with rheumatoid arthritis of multiple sites 40 40 40 83 Yes Yes Yes Yes
M0549 Rheumatoid myopathy with rheumatoid arthritis of multiple sites 75 Yes -- -- --
M0550 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site 40 40 40 83 Yes Yes Yes Yes
M0550 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site 75 75 75 159 Yes Yes Yes Yes
M05511 Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder 40 40 40 83 Yes Yes Yes Yes
M05511 Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder 75 75 75 159 Yes Yes Yes Yes
M05512 Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder 40 40 40 83 Yes Yes Yes Yes
M05512 Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder 75 75 75 159 Yes Yes Yes Yes
M05519 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified shoulder 40 40 40 83 Yes Yes Yes Yes
M05519 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified shoulder 75 75 75 159 Yes Yes Yes Yes
M05521 Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow 40 40 40 83 Yes Yes Yes Yes
M05521 Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow 75 75 75 159 Yes Yes Yes Yes
M05522 Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow 40 40 40 83 Yes Yes Yes Yes
M05522 Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow 75 75 75 159 Yes Yes Yes Yes
M05529 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified elbow 40 40 40 83 Yes Yes Yes Yes
M05529 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified elbow 75 75 75 159 Yes Yes Yes Yes
M05531 Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist 40 40 40 83 Yes Yes Yes Yes
M05531 Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist 75 75 75 159 Yes Yes Yes Yes
M05532 Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist 40 40 40 83 Yes Yes Yes Yes
M05532 Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist 75 75 75 159 Yes Yes Yes Yes
M05539 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified wrist 40 40 40 83 Yes Yes Yes Yes
M05539 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified wrist 75 75 75 159 Yes Yes Yes Yes
M05541 Rheumatoid polyneuropathy with rheumatoid arthritis of right hand 40 40 40 83 Yes Yes Yes Yes
M05541 Rheumatoid polyneuropathy with rheumatoid arthritis of right hand 75 75 75 159 Yes Yes Yes Yes
M05542 Rheumatoid polyneuropathy with rheumatoid arthritis of left hand 40 40 40 83 Yes Yes Yes Yes
M05542 Rheumatoid polyneuropathy with rheumatoid arthritis of left hand 75 75 75 159 Yes Yes Yes Yes
M05549 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hand 40 40 40 83 Yes Yes Yes Yes
M05549 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hand 75 75 75 159 Yes Yes Yes Yes
M05551 Rheumatoid polyneuropathy with rheumatoid arthritis of right hip 40 40 40 83 Yes Yes Yes Yes
M05551 Rheumatoid polyneuropathy with rheumatoid arthritis of right hip 75 75 75 159 Yes Yes Yes Yes
M05552 Rheumatoid polyneuropathy with rheumatoid arthritis of left hip 40 40 40 83 Yes Yes Yes Yes
M05552 Rheumatoid polyneuropathy with rheumatoid arthritis of left hip 75 75 75 159 Yes Yes Yes Yes
M05559 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hip 40 40 40 83 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 132 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M05559 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hip 75 75 75 159 Yes Yes Yes Yes
M05561 Rheumatoid polyneuropathy with rheumatoid arthritis of right knee 40 40 40 83 Yes Yes Yes Yes
M05561 Rheumatoid polyneuropathy with rheumatoid arthritis of right knee 75 75 75 159 Yes Yes Yes Yes
M05562 Rheumatoid polyneuropathy with rheumatoid arthritis of left knee 40 40 40 83 Yes Yes Yes Yes
M05562 Rheumatoid polyneuropathy with rheumatoid arthritis of left knee 75 75 75 159 Yes Yes Yes Yes
M05569 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee 40 40 40 83 Yes Yes Yes Yes
M05569 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee 75 75 75 159 Yes Yes Yes Yes
M05571 Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot 40 40 40 83 Yes Yes Yes Yes
M05571 Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot 75 75 75 159 Yes Yes Yes Yes
M05572 Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot 40 40 40 83 Yes Yes Yes Yes
M05572 Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot 75 75 75 159 Yes Yes Yes Yes
M05579 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and foot 40 40 40 83 Yes Yes Yes Yes
M05579 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and foot 75 75 75 159 Yes Yes Yes Yes
M0559 Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites 40 40 40 83 Yes Yes Yes Yes
M0559 Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites 75 75 75 159 Yes Yes Yes Yes
M0560 Rheumatoid arthritis of unspecified site with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05611 Rheumatoid arthritis of right shoulder with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05612 Rheumatoid arthritis of left shoulder with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05619 Rheumatoid arthritis of unspecified shoulder with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05621 Rheumatoid arthritis of right elbow with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05622 Rheumatoid arthritis of left elbow with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05629 Rheumatoid arthritis of unspecified elbow with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05631 Rheumatoid arthritis of right wrist with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05632 Rheumatoid arthritis of left wrist with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05639 Rheumatoid arthritis of unspecified wrist with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05641 Rheumatoid arthritis of right hand with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05642 Rheumatoid arthritis of left hand with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05649 Rheumatoid arthritis of unspecified hand with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05651 Rheumatoid arthritis of right hip with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05652 Rheumatoid arthritis of left hip with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05659 Rheumatoid arthritis of unspecified hip with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05661 Rheumatoid arthritis of right knee with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05662 Rheumatoid arthritis of left knee with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05669 Rheumatoid arthritis of unspecified knee with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05671 Rheumatoid arthritis of right ankle and foot with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05672 Rheumatoid arthritis of left ankle and foot with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M05679 Rheumatoid arthritis of unspecified ankle and foot with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M0569 Rheumatoid arthritis of multiple sites with involvement of other organs and systems 40 40 40 83 Yes Yes Yes Yes
M0570 Rheumatoid arthritis with rheumatoid factor of unspecified site without organ or systems 40 40 40 83 Yes Yes Yes Yes
involvement
M05711 Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systems involvement 40 40 40 83 Yes Yes Yes Yes
M05712 Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvement 40 40 40 83 Yes Yes Yes Yes
M05719 Rheumatoid arthritis with rheumatoid factor of unspecified shoulder without organ or systems 40 40 40 83 Yes Yes Yes Yes
involvement
M05721 Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvement 40 40 40 83 Yes Yes Yes Yes
M05722 Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvement 40 40 40 83 Yes Yes Yes Yes
M05729 Rheumatoid arthritis with rheumatoid factor of unspecified elbow without organ or systems 40 40 40 83 Yes Yes Yes Yes
involvement
M05731 Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvement 40 40 40 83 Yes Yes Yes Yes
M05732 Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvement 40 40 40 83 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 133 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M05739 Rheumatoid arthritis with rheumatoid factor of unspecified wrist without organ or systems 40 40 40 83 Yes Yes Yes Yes
involvement
M05741 Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvement 40 40 40 83 Yes Yes Yes Yes
M05742 Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvement 40 40 40 83 Yes Yes Yes Yes
M05749 Rheumatoid arthritis with rheumatoid factor of unspecified hand without organ or systems 40 40 40 83 Yes Yes Yes Yes
involvement
M05751 Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvement 40 40 40 83 Yes Yes Yes Yes
M05752 Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement 40 40 40 83 Yes Yes Yes Yes
M05759 Rheumatoid arthritis with rheumatoid factor of unspecified hip without organ or systems 40 40 40 83 Yes Yes Yes Yes
involvement
M05761 Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement 40 40 40 83 Yes Yes Yes Yes
M05762 Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement 40 40 40 83 Yes Yes Yes Yes
M05769 Rheumatoid arthritis with rheumatoid factor of unspecified knee without organ or systems 40 40 40 83 Yes Yes Yes Yes
involvement
M05771 Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems 40 40 40 83 Yes Yes Yes Yes
involvement
M05772 Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems 40 40 40 83 Yes Yes Yes Yes
involvement
M05779 Rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot without organ or systems 40 40 40 83 Yes Yes Yes Yes
involvement
M0579 Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement 40 40 40 83 Yes Yes Yes Yes
M057A Rheumatoid arthritis with rheumatoid factor of other specified site without organ or systems 40 40 40 83 Yes Yes Yes Yes
involvement
M0580 Other rheumatoid arthritis with rheumatoid factor of unspecified site 40 40 40 83 Yes Yes Yes Yes
M05811 Other rheumatoid arthritis with rheumatoid factor of right shoulder 40 40 40 83 Yes Yes Yes Yes
M05812 Other rheumatoid arthritis with rheumatoid factor of left shoulder 40 40 40 83 Yes Yes Yes Yes
M05819 Other rheumatoid arthritis with rheumatoid factor of unspecified shoulder 40 40 40 83 Yes Yes Yes Yes
M05821 Other rheumatoid arthritis with rheumatoid factor of right elbow 40 40 40 83 Yes Yes Yes Yes
M05822 Other rheumatoid arthritis with rheumatoid factor of left elbow 40 40 40 83 Yes Yes Yes Yes
M05829 Other rheumatoid arthritis with rheumatoid factor of unspecified elbow 40 40 40 83 Yes Yes Yes Yes
M05831 Other rheumatoid arthritis with rheumatoid factor of right wrist 40 40 40 83 Yes Yes Yes Yes
M05832 Other rheumatoid arthritis with rheumatoid factor of left wrist 40 40 40 83 Yes Yes Yes Yes
M05839 Other rheumatoid arthritis with rheumatoid factor of unspecified wrist 40 40 40 83 Yes Yes Yes Yes
M05841 Other rheumatoid arthritis with rheumatoid factor of right hand 40 40 40 83 Yes Yes Yes Yes
M05842 Other rheumatoid arthritis with rheumatoid factor of left hand 40 40 40 83 Yes Yes Yes Yes
M05849 Other rheumatoid arthritis with rheumatoid factor of unspecified hand 40 40 40 83 Yes Yes Yes Yes
M05851 Other rheumatoid arthritis with rheumatoid factor of right hip 40 40 40 83 Yes Yes Yes Yes
M05852 Other rheumatoid arthritis with rheumatoid factor of left hip 40 40 40 83 Yes Yes Yes Yes
M05859 Other rheumatoid arthritis with rheumatoid factor of unspecified hip 40 40 40 83 Yes Yes Yes Yes
M05861 Other rheumatoid arthritis with rheumatoid factor of right knee 40 40 40 83 Yes Yes Yes Yes
M05862 Other rheumatoid arthritis with rheumatoid factor of left knee 40 40 40 83 Yes Yes Yes Yes
M05869 Other rheumatoid arthritis with rheumatoid factor of unspecified knee 40 40 40 83 Yes Yes Yes Yes
M05871 Other rheumatoid arthritis with rheumatoid factor of right ankle and foot 40 40 40 83 Yes Yes Yes Yes
M05872 Other rheumatoid arthritis with rheumatoid factor of left ankle and foot 40 40 40 83 Yes Yes Yes Yes
M05879 Other rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot 40 40 40 83 Yes Yes Yes Yes
M0589 Other rheumatoid arthritis with rheumatoid factor of multiple sites 40 40 40 83 Yes Yes Yes Yes
M058A Other rheumatoid arthritis with rheumatoid factor of other specified site 40 40 40 83 Yes Yes Yes Yes
M059 Rheumatoid arthritis with rheumatoid factor, unspecified 40 40 40 83 Yes Yes Yes Yes
M0600 Rheumatoid arthritis without rheumatoid factor, unspecified site 40 40 40 83 Yes Yes Yes Yes
M06011 Rheumatoid arthritis without rheumatoid factor, right shoulder 40 40 40 83 Yes Yes Yes Yes
M06012 Rheumatoid arthritis without rheumatoid factor, left shoulder 40 40 40 83 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 134 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M06019 Rheumatoid arthritis without rheumatoid factor, unspecified shoulder 40 40 40 83 Yes Yes Yes Yes
M06021 Rheumatoid arthritis without rheumatoid factor, right elbow 40 40 40 83 Yes Yes Yes Yes
M06022 Rheumatoid arthritis without rheumatoid factor, left elbow 40 40 40 83 Yes Yes Yes Yes
M06029 Rheumatoid arthritis without rheumatoid factor, unspecified elbow 40 40 40 83 Yes Yes Yes Yes
M06031 Rheumatoid arthritis without rheumatoid factor, right wrist 40 40 40 83 Yes Yes Yes Yes
M06032 Rheumatoid arthritis without rheumatoid factor, left wrist 40 40 40 83 Yes Yes Yes Yes
M06039 Rheumatoid arthritis without rheumatoid factor, unspecified wrist 40 40 40 83 Yes Yes Yes Yes
M06041 Rheumatoid arthritis without rheumatoid factor, right hand 40 40 40 83 Yes Yes Yes Yes
M06042 Rheumatoid arthritis without rheumatoid factor, left hand 40 40 40 83 Yes Yes Yes Yes
M06049 Rheumatoid arthritis without rheumatoid factor, unspecified hand 40 40 40 83 Yes Yes Yes Yes
M06051 Rheumatoid arthritis without rheumatoid factor, right hip 40 40 40 83 Yes Yes Yes Yes
M06052 Rheumatoid arthritis without rheumatoid factor, left hip 40 40 40 83 Yes Yes Yes Yes
M06059 Rheumatoid arthritis without rheumatoid factor, unspecified hip 40 40 40 83 Yes Yes Yes Yes
M06061 Rheumatoid arthritis without rheumatoid factor, right knee 40 40 40 83 Yes Yes Yes Yes
M06062 Rheumatoid arthritis without rheumatoid factor, left knee 40 40 40 83 Yes Yes Yes Yes
M06069 Rheumatoid arthritis without rheumatoid factor, unspecified knee 40 40 40 83 Yes Yes Yes Yes
M06071 Rheumatoid arthritis without rheumatoid factor, right ankle and foot 40 40 40 83 Yes Yes Yes Yes
M06072 Rheumatoid arthritis without rheumatoid factor, left ankle and foot 40 40 40 83 Yes Yes Yes Yes
M06079 Rheumatoid arthritis without rheumatoid factor, unspecified ankle and foot 40 40 40 83 Yes Yes Yes Yes
M0608 Rheumatoid arthritis without rheumatoid factor, vertebrae 40 40 40 83 Yes Yes Yes Yes
M0609 Rheumatoid arthritis without rheumatoid factor, multiple sites 40 40 40 83 Yes Yes Yes Yes
M060A Rheumatoid arthritis without rheumatoid factor, other specified site 40 40 40 83 Yes Yes Yes Yes
M061 Adult-onset Still's disease 40 40 40 83 Yes Yes Yes Yes
M0620 Rheumatoid bursitis, unspecified site 40 40 40 83 Yes Yes Yes Yes
M06211 Rheumatoid bursitis, right shoulder 40 40 40 83 Yes Yes Yes Yes
M06212 Rheumatoid bursitis, left shoulder 40 40 40 83 Yes Yes Yes Yes
M06219 Rheumatoid bursitis, unspecified shoulder 40 40 40 83 Yes Yes Yes Yes
M06221 Rheumatoid bursitis, right elbow 40 40 40 83 Yes Yes Yes Yes
M06222 Rheumatoid bursitis, left elbow 40 40 40 83 Yes Yes Yes Yes
M06229 Rheumatoid bursitis, unspecified elbow 40 40 40 83 Yes Yes Yes Yes
M06231 Rheumatoid bursitis, right wrist 40 40 40 83 Yes Yes Yes Yes
M06232 Rheumatoid bursitis, left wrist 40 40 40 83 Yes Yes Yes Yes
M06239 Rheumatoid bursitis, unspecified wrist 40 40 40 83 Yes Yes Yes Yes
M06241 Rheumatoid bursitis, right hand 40 40 40 83 Yes Yes Yes Yes
M06242 Rheumatoid bursitis, left hand 40 40 40 83 Yes Yes Yes Yes
M06249 Rheumatoid bursitis, unspecified hand 40 40 40 83 Yes Yes Yes Yes
M06251 Rheumatoid bursitis, right hip 40 40 40 83 Yes Yes Yes Yes
M06252 Rheumatoid bursitis, left hip 40 40 40 83 Yes Yes Yes Yes
M06259 Rheumatoid bursitis, unspecified hip 40 40 40 83 Yes Yes Yes Yes
M06261 Rheumatoid bursitis, right knee 40 40 40 83 Yes Yes Yes Yes
M06262 Rheumatoid bursitis, left knee 40 40 40 83 Yes Yes Yes Yes
M06269 Rheumatoid bursitis, unspecified knee 40 40 40 83 Yes Yes Yes Yes
M06271 Rheumatoid bursitis, right ankle and foot 40 40 40 83 Yes Yes Yes Yes
M06272 Rheumatoid bursitis, left ankle and foot 40 40 40 83 Yes Yes Yes Yes
M06279 Rheumatoid bursitis, unspecified ankle and foot 40 40 40 83 Yes Yes Yes Yes
M0628 Rheumatoid bursitis, vertebrae 40 40 40 83 Yes Yes Yes Yes
M0629 Rheumatoid bursitis, multiple sites 40 40 40 83 Yes Yes Yes Yes
M0630 Rheumatoid nodule, unspecified site 40 40 40 83 Yes Yes Yes Yes
M06311 Rheumatoid nodule, right shoulder 40 40 40 83 Yes Yes Yes Yes
M06312 Rheumatoid nodule, left shoulder 40 40 40 83 Yes Yes Yes Yes
M06319 Rheumatoid nodule, unspecified shoulder 40 40 40 83 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 135 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M06321 Rheumatoid nodule, right elbow 40 40 40 83 Yes Yes Yes Yes


M06322 Rheumatoid nodule, left elbow 40 40 40 83 Yes Yes Yes Yes
M06329 Rheumatoid nodule, unspecified elbow 40 40 40 83 Yes Yes Yes Yes
M06331 Rheumatoid nodule, right wrist 40 40 40 83 Yes Yes Yes Yes
M06332 Rheumatoid nodule, left wrist 40 40 40 83 Yes Yes Yes Yes
M06339 Rheumatoid nodule, unspecified wrist 40 40 40 83 Yes Yes Yes Yes
M06341 Rheumatoid nodule, right hand 40 40 40 83 Yes Yes Yes Yes
M06342 Rheumatoid nodule, left hand 40 40 40 83 Yes Yes Yes Yes
M06349 Rheumatoid nodule, unspecified hand 40 40 40 83 Yes Yes Yes Yes
M06351 Rheumatoid nodule, right hip 40 40 40 83 Yes Yes Yes Yes
M06352 Rheumatoid nodule, left hip 40 40 40 83 Yes Yes Yes Yes
M06359 Rheumatoid nodule, unspecified hip 40 40 40 83 Yes Yes Yes Yes
M06361 Rheumatoid nodule, right knee 40 40 40 83 Yes Yes Yes Yes
M06362 Rheumatoid nodule, left knee 40 40 40 83 Yes Yes Yes Yes
M06369 Rheumatoid nodule, unspecified knee 40 40 40 83 Yes Yes Yes Yes
M06371 Rheumatoid nodule, right ankle and foot 40 40 40 83 Yes Yes Yes Yes
M06372 Rheumatoid nodule, left ankle and foot 40 40 40 83 Yes Yes Yes Yes
M06379 Rheumatoid nodule, unspecified ankle and foot 40 40 40 83 Yes Yes Yes Yes
M0638 Rheumatoid nodule, vertebrae 40 40 40 83 Yes Yes Yes Yes
M0639 Rheumatoid nodule, multiple sites 40 40 40 83 Yes Yes Yes Yes
M064 Inflammatory polyarthropathy 40 40 40 83 Yes Yes Yes Yes
M0680 Other specified rheumatoid arthritis, unspecified site 40 40 40 83 Yes Yes Yes Yes
M06811 Other specified rheumatoid arthritis, right shoulder 40 40 40 83 Yes Yes Yes Yes
M06812 Other specified rheumatoid arthritis, left shoulder 40 40 40 83 Yes Yes Yes Yes
M06819 Other specified rheumatoid arthritis, unspecified shoulder 40 40 40 83 Yes Yes Yes Yes
M06821 Other specified rheumatoid arthritis, right elbow 40 40 40 83 Yes Yes Yes Yes
M06822 Other specified rheumatoid arthritis, left elbow 40 40 40 83 Yes Yes Yes Yes
M06829 Other specified rheumatoid arthritis, unspecified elbow 40 40 40 83 Yes Yes Yes Yes
M06831 Other specified rheumatoid arthritis, right wrist 40 40 40 83 Yes Yes Yes Yes
M06832 Other specified rheumatoid arthritis, left wrist 40 40 40 83 Yes Yes Yes Yes
M06839 Other specified rheumatoid arthritis, unspecified wrist 40 40 40 83 Yes Yes Yes Yes
M06841 Other specified rheumatoid arthritis, right hand 40 40 40 83 Yes Yes Yes Yes
M06842 Other specified rheumatoid arthritis, left hand 40 40 40 83 Yes Yes Yes Yes
M06849 Other specified rheumatoid arthritis, unspecified hand 40 40 40 83 Yes Yes Yes Yes
M06851 Other specified rheumatoid arthritis, right hip 40 40 40 83 Yes Yes Yes Yes
M06852 Other specified rheumatoid arthritis, left hip 40 40 40 83 Yes Yes Yes Yes
M06859 Other specified rheumatoid arthritis, unspecified hip 40 40 40 83 Yes Yes Yes Yes
M06861 Other specified rheumatoid arthritis, right knee 40 40 40 83 Yes Yes Yes Yes
M06862 Other specified rheumatoid arthritis, left knee 40 40 40 83 Yes Yes Yes Yes
M06869 Other specified rheumatoid arthritis, unspecified knee 40 40 40 83 Yes Yes Yes Yes
M06871 Other specified rheumatoid arthritis, right ankle and foot 40 40 40 83 Yes Yes Yes Yes
M06872 Other specified rheumatoid arthritis, left ankle and foot 40 40 40 83 Yes Yes Yes Yes
M06879 Other specified rheumatoid arthritis, unspecified ankle and foot 40 40 40 83 Yes Yes Yes Yes
M0688 Other specified rheumatoid arthritis, vertebrae 40 40 40 83 Yes Yes Yes Yes
M0689 Other specified rheumatoid arthritis, multiple sites 40 40 40 83 Yes Yes Yes Yes
M068A Other specified rheumatoid arthritis, other specified site 40 40 40 83 Yes Yes Yes Yes
M069 Rheumatoid arthritis, unspecified 40 40 40 83 Yes Yes Yes Yes
M0800 Unspecified juvenile rheumatoid arthritis of unspecified site 40 40 40 83 Yes Yes Yes Yes
M08011 Unspecified juvenile rheumatoid arthritis, right shoulder 40 40 40 83 Yes Yes Yes Yes
M08012 Unspecified juvenile rheumatoid arthritis, left shoulder 40 40 40 83 Yes Yes Yes Yes
M08019 Unspecified juvenile rheumatoid arthritis, unspecified shoulder 40 40 40 83 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 136 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M08021 Unspecified juvenile rheumatoid arthritis, right elbow 40 40 40 83 Yes Yes Yes Yes
M08022 Unspecified juvenile rheumatoid arthritis, left elbow 40 40 40 83 Yes Yes Yes Yes
M08029 Unspecified juvenile rheumatoid arthritis, unspecified elbow 40 40 40 83 Yes Yes Yes Yes
M08031 Unspecified juvenile rheumatoid arthritis, right wrist 40 40 40 83 Yes Yes Yes Yes
M08032 Unspecified juvenile rheumatoid arthritis, left wrist 40 40 40 83 Yes Yes Yes Yes
M08039 Unspecified juvenile rheumatoid arthritis, unspecified wrist 40 40 40 83 Yes Yes Yes Yes
M08041 Unspecified juvenile rheumatoid arthritis, right hand 40 40 40 83 Yes Yes Yes Yes
M08042 Unspecified juvenile rheumatoid arthritis, left hand 40 40 40 83 Yes Yes Yes Yes
M08049 Unspecified juvenile rheumatoid arthritis, unspecified hand 40 40 40 83 Yes Yes Yes Yes
M08051 Unspecified juvenile rheumatoid arthritis, right hip 40 40 40 83 Yes Yes Yes Yes
M08052 Unspecified juvenile rheumatoid arthritis, left hip 40 40 40 83 Yes Yes Yes Yes
M08059 Unspecified juvenile rheumatoid arthritis, unspecified hip 40 40 40 83 Yes Yes Yes Yes
M08061 Unspecified juvenile rheumatoid arthritis, right knee 40 40 40 83 Yes Yes Yes Yes
M08062 Unspecified juvenile rheumatoid arthritis, left knee 40 40 40 83 Yes Yes Yes Yes
M08069 Unspecified juvenile rheumatoid arthritis, unspecified knee 40 40 40 83 Yes Yes Yes Yes
M08071 Unspecified juvenile rheumatoid arthritis, right ankle and foot 40 40 40 83 Yes Yes Yes Yes
M08072 Unspecified juvenile rheumatoid arthritis, left ankle and foot 40 40 40 83 Yes Yes Yes Yes
M08079 Unspecified juvenile rheumatoid arthritis, unspecified ankle and foot 40 40 40 83 Yes Yes Yes Yes
M0808 Unspecified juvenile rheumatoid arthritis, vertebrae 40 40 40 83 Yes Yes Yes Yes
M0809 Unspecified juvenile rheumatoid arthritis, multiple sites 40 40 40 83 Yes Yes Yes Yes
M080A Unspecified juvenile rheumatoid arthritis, other specified site 40 40 40 83 Yes Yes Yes Yes
M081 Juvenile ankylosing spondylitis 40 40 40 84 Yes Yes Yes Yes
M0820 Juvenile rheumatoid arthritis with systemic onset, unspecified site 40 40 40 83 Yes Yes Yes Yes
M08211 Juvenile rheumatoid arthritis with systemic onset, right shoulder 40 40 40 83 Yes Yes Yes Yes
M08212 Juvenile rheumatoid arthritis with systemic onset, left shoulder 40 40 40 83 Yes Yes Yes Yes
M08219 Juvenile rheumatoid arthritis with systemic onset, unspecified shoulder 40 40 40 83 Yes Yes Yes Yes
M08221 Juvenile rheumatoid arthritis with systemic onset, right elbow 40 40 40 83 Yes Yes Yes Yes
M08222 Juvenile rheumatoid arthritis with systemic onset, left elbow 40 40 40 83 Yes Yes Yes Yes
M08229 Juvenile rheumatoid arthritis with systemic onset, unspecified elbow 40 40 40 83 Yes Yes Yes Yes
M08231 Juvenile rheumatoid arthritis with systemic onset, right wrist 40 40 40 83 Yes Yes Yes Yes
M08232 Juvenile rheumatoid arthritis with systemic onset, left wrist 40 40 40 83 Yes Yes Yes Yes
M08239 Juvenile rheumatoid arthritis with systemic onset, unspecified wrist 40 40 40 83 Yes Yes Yes Yes
M08241 Juvenile rheumatoid arthritis with systemic onset, right hand 40 40 40 83 Yes Yes Yes Yes
M08242 Juvenile rheumatoid arthritis with systemic onset, left hand 40 40 40 83 Yes Yes Yes Yes
M08249 Juvenile rheumatoid arthritis with systemic onset, unspecified hand 40 40 40 83 Yes Yes Yes Yes
M08251 Juvenile rheumatoid arthritis with systemic onset, right hip 40 40 40 83 Yes Yes Yes Yes
M08252 Juvenile rheumatoid arthritis with systemic onset, left hip 40 40 40 83 Yes Yes Yes Yes
M08259 Juvenile rheumatoid arthritis with systemic onset, unspecified hip 40 40 40 83 Yes Yes Yes Yes
M08261 Juvenile rheumatoid arthritis with systemic onset, right knee 40 40 40 83 Yes Yes Yes Yes
M08262 Juvenile rheumatoid arthritis with systemic onset, left knee 40 40 40 83 Yes Yes Yes Yes
M08269 Juvenile rheumatoid arthritis with systemic onset, unspecified knee 40 40 40 83 Yes Yes Yes Yes
M08271 Juvenile rheumatoid arthritis with systemic onset, right ankle and foot 40 40 40 83 Yes Yes Yes Yes
M08272 Juvenile rheumatoid arthritis with systemic onset, left ankle and foot 40 40 40 83 Yes Yes Yes Yes
M08279 Juvenile rheumatoid arthritis with systemic onset, unspecified ankle and foot 40 40 40 83 Yes Yes Yes Yes
M0828 Juvenile rheumatoid arthritis with systemic onset, vertebrae 40 40 40 83 Yes Yes Yes Yes
M0829 Juvenile rheumatoid arthritis with systemic onset, multiple sites 40 40 40 83 Yes Yes Yes Yes
M082A Juvenile rheumatoid arthritis with systemic onset, other specified site 40 40 40 83 Yes Yes Yes Yes
M083 Juvenile rheumatoid polyarthritis (seronegative) 40 40 40 83 Yes Yes Yes Yes
M0840 Pauciarticular juvenile rheumatoid arthritis, unspecified site 40 40 40 83 Yes Yes Yes Yes
M08411 Pauciarticular juvenile rheumatoid arthritis, right shoulder 40 40 40 83 Yes Yes Yes Yes
M08412 Pauciarticular juvenile rheumatoid arthritis, left shoulder 40 40 40 83 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 137 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M08419 Pauciarticular juvenile rheumatoid arthritis, unspecified shoulder 40 40 40 83 Yes Yes Yes Yes
M08421 Pauciarticular juvenile rheumatoid arthritis, right elbow 40 40 40 83 Yes Yes Yes Yes
M08422 Pauciarticular juvenile rheumatoid arthritis, left elbow 40 40 40 83 Yes Yes Yes Yes
M08429 Pauciarticular juvenile rheumatoid arthritis, unspecified elbow 40 40 40 83 Yes Yes Yes Yes
M08431 Pauciarticular juvenile rheumatoid arthritis, right wrist 40 40 40 83 Yes Yes Yes Yes
M08432 Pauciarticular juvenile rheumatoid arthritis, left wrist 40 40 40 83 Yes Yes Yes Yes
M08439 Pauciarticular juvenile rheumatoid arthritis, unspecified wrist 40 40 40 83 Yes Yes Yes Yes
M08441 Pauciarticular juvenile rheumatoid arthritis, right hand 40 40 40 83 Yes Yes Yes Yes
M08442 Pauciarticular juvenile rheumatoid arthritis, left hand 40 40 40 83 Yes Yes Yes Yes
M08449 Pauciarticular juvenile rheumatoid arthritis, unspecified hand 40 40 40 83 Yes Yes Yes Yes
M08451 Pauciarticular juvenile rheumatoid arthritis, right hip 40 40 40 83 Yes Yes Yes Yes
M08452 Pauciarticular juvenile rheumatoid arthritis, left hip 40 40 40 83 Yes Yes Yes Yes
M08459 Pauciarticular juvenile rheumatoid arthritis, unspecified hip 40 40 40 83 Yes Yes Yes Yes
M08461 Pauciarticular juvenile rheumatoid arthritis, right knee 40 40 40 83 Yes Yes Yes Yes
M08462 Pauciarticular juvenile rheumatoid arthritis, left knee 40 40 40 83 Yes Yes Yes Yes
M08469 Pauciarticular juvenile rheumatoid arthritis, unspecified knee 40 40 40 83 Yes Yes Yes Yes
M08471 Pauciarticular juvenile rheumatoid arthritis, right ankle and foot 40 40 40 83 Yes Yes Yes Yes
M08472 Pauciarticular juvenile rheumatoid arthritis, left ankle and foot 40 40 40 83 Yes Yes Yes Yes
M08479 Pauciarticular juvenile rheumatoid arthritis, unspecified ankle and foot 40 40 40 83 Yes Yes Yes Yes
M0848 Pauciarticular juvenile rheumatoid arthritis, vertebrae 40 40 40 83 Yes Yes Yes Yes
M084A Pauciarticular juvenile rheumatoid arthritis, other specified site 40 40 40 83 Yes Yes Yes Yes
M0880 Other juvenile arthritis, unspecified site 40 40 40 83 Yes Yes Yes Yes
M08811 Other juvenile arthritis, right shoulder 40 40 40 83 Yes Yes Yes Yes
M08812 Other juvenile arthritis, left shoulder 40 40 40 83 Yes Yes Yes Yes
M08819 Other juvenile arthritis, unspecified shoulder 40 40 40 83 Yes Yes Yes Yes
M08821 Other juvenile arthritis, right elbow 40 40 40 83 Yes Yes Yes Yes
M08822 Other juvenile arthritis, left elbow 40 40 40 83 Yes Yes Yes Yes
M08829 Other juvenile arthritis, unspecified elbow 40 40 40 83 Yes Yes Yes Yes
M08831 Other juvenile arthritis, right wrist 40 40 40 83 Yes Yes Yes Yes
M08832 Other juvenile arthritis, left wrist 40 40 40 83 Yes Yes Yes Yes
M08839 Other juvenile arthritis, unspecified wrist 40 40 40 83 Yes Yes Yes Yes
M08841 Other juvenile arthritis, right hand 40 40 40 83 Yes Yes Yes Yes
M08842 Other juvenile arthritis, left hand 40 40 40 83 Yes Yes Yes Yes
M08849 Other juvenile arthritis, unspecified hand 40 40 40 83 Yes Yes Yes Yes
M08851 Other juvenile arthritis, right hip 40 40 40 83 Yes Yes Yes Yes
M08852 Other juvenile arthritis, left hip 40 40 40 83 Yes Yes Yes Yes
M08859 Other juvenile arthritis, unspecified hip 40 40 40 83 Yes Yes Yes Yes
M08861 Other juvenile arthritis, right knee 40 40 40 83 Yes Yes Yes Yes
M08862 Other juvenile arthritis, left knee 40 40 40 83 Yes Yes Yes Yes
M08869 Other juvenile arthritis, unspecified knee 40 40 40 83 Yes Yes Yes Yes
M08871 Other juvenile arthritis, right ankle and foot 40 40 40 83 Yes Yes Yes Yes
M08872 Other juvenile arthritis, left ankle and foot 40 40 40 83 Yes Yes Yes Yes
M08879 Other juvenile arthritis, unspecified ankle and foot 40 40 40 83 Yes Yes Yes Yes
M0888 Other juvenile arthritis, other specified site 40 40 40 83 Yes Yes Yes Yes
M0889 Other juvenile arthritis, multiple sites 40 40 40 83 Yes Yes Yes Yes
M0890 Juvenile arthritis, unspecified, unspecified site 40 40 40 83 Yes Yes Yes Yes
M08911 Juvenile arthritis, unspecified, right shoulder 40 40 40 83 Yes Yes Yes Yes
M08912 Juvenile arthritis, unspecified, left shoulder 40 40 40 83 Yes Yes Yes Yes
M08919 Juvenile arthritis, unspecified, unspecified shoulder 40 40 40 83 Yes Yes Yes Yes
M08921 Juvenile arthritis, unspecified, right elbow 40 40 40 83 Yes Yes Yes Yes
M08922 Juvenile arthritis, unspecified, left elbow 40 40 40 83 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 138 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M08929 Juvenile arthritis, unspecified, unspecified elbow 40 40 40 83 Yes Yes Yes Yes
M08931 Juvenile arthritis, unspecified, right wrist 40 40 40 83 Yes Yes Yes Yes
M08932 Juvenile arthritis, unspecified, left wrist 40 40 40 83 Yes Yes Yes Yes
M08939 Juvenile arthritis, unspecified, unspecified wrist 40 40 40 83 Yes Yes Yes Yes
M08941 Juvenile arthritis, unspecified, right hand 40 40 40 83 Yes Yes Yes Yes
M08942 Juvenile arthritis, unspecified, left hand 40 40 40 83 Yes Yes Yes Yes
M08949 Juvenile arthritis, unspecified, unspecified hand 40 40 40 83 Yes Yes Yes Yes
M08951 Juvenile arthritis, unspecified, right hip 40 40 40 83 Yes Yes Yes Yes
M08952 Juvenile arthritis, unspecified, left hip 40 40 40 83 Yes Yes Yes Yes
M08959 Juvenile arthritis, unspecified, unspecified hip 40 40 40 83 Yes Yes Yes Yes
M08961 Juvenile arthritis, unspecified, right knee 40 40 40 83 Yes Yes Yes Yes
M08962 Juvenile arthritis, unspecified, left knee 40 40 40 83 Yes Yes Yes Yes
M08969 Juvenile arthritis, unspecified, unspecified knee 40 40 40 83 Yes Yes Yes Yes
M08971 Juvenile arthritis, unspecified, right ankle and foot 40 40 40 83 Yes Yes Yes Yes
M08972 Juvenile arthritis, unspecified, left ankle and foot 40 40 40 83 Yes Yes Yes Yes
M08979 Juvenile arthritis, unspecified, unspecified ankle and foot 40 40 40 83 Yes Yes Yes Yes
M0898 Juvenile arthritis, unspecified, vertebrae 40 40 40 83 Yes Yes Yes Yes
M0899 Juvenile arthritis, unspecified, multiple sites 40 40 40 83 Yes Yes Yes Yes
M089A Juvenile arthritis, unspecified, other specified site 40 40 40 83 Yes Yes Yes Yes
M1200 Chronic postrheumatic arthropathy [Jaccoud], unspecified site 40 40 40 83 Yes Yes Yes Yes
M12011 Chronic postrheumatic arthropathy [Jaccoud], right shoulder 40 40 40 83 Yes Yes Yes Yes
M12012 Chronic postrheumatic arthropathy [Jaccoud], left shoulder 40 40 40 83 Yes Yes Yes Yes
M12019 Chronic postrheumatic arthropathy [Jaccoud], unspecified shoulder 40 40 40 83 Yes Yes Yes Yes
M12021 Chronic postrheumatic arthropathy [Jaccoud], right elbow 40 40 40 83 Yes Yes Yes Yes
M12022 Chronic postrheumatic arthropathy [Jaccoud], left elbow 40 40 40 83 Yes Yes Yes Yes
M12029 Chronic postrheumatic arthropathy [Jaccoud], unspecified elbow 40 40 40 83 Yes Yes Yes Yes
M12031 Chronic postrheumatic arthropathy [Jaccoud], right wrist 40 40 40 83 Yes Yes Yes Yes
M12032 Chronic postrheumatic arthropathy [Jaccoud], left wrist 40 40 40 83 Yes Yes Yes Yes
M12039 Chronic postrheumatic arthropathy [Jaccoud], unspecified wrist 40 40 40 83 Yes Yes Yes Yes
M12041 Chronic postrheumatic arthropathy [Jaccoud], right hand 40 40 40 83 Yes Yes Yes Yes
M12042 Chronic postrheumatic arthropathy [Jaccoud], left hand 40 40 40 83 Yes Yes Yes Yes
M12049 Chronic postrheumatic arthropathy [Jaccoud], unspecified hand 40 40 40 83 Yes Yes Yes Yes
M12051 Chronic postrheumatic arthropathy [Jaccoud], right hip 40 40 40 83 Yes Yes Yes Yes
M12052 Chronic postrheumatic arthropathy [Jaccoud], left hip 40 40 40 83 Yes Yes Yes Yes
M12059 Chronic postrheumatic arthropathy [Jaccoud], unspecified hip 40 40 40 83 Yes Yes Yes Yes
M12061 Chronic postrheumatic arthropathy [Jaccoud], right knee 40 40 40 83 Yes Yes Yes Yes
M12062 Chronic postrheumatic arthropathy [Jaccoud], left knee 40 40 40 83 Yes Yes Yes Yes
M12069 Chronic postrheumatic arthropathy [Jaccoud], unspecified knee 40 40 40 83 Yes Yes Yes Yes
M12071 Chronic postrheumatic arthropathy [Jaccoud], right ankle and foot 40 40 40 83 Yes Yes Yes Yes
M12072 Chronic postrheumatic arthropathy [Jaccoud], left ankle and foot 40 40 40 83 Yes Yes Yes Yes
M12079 Chronic postrheumatic arthropathy [Jaccoud], unspecified ankle and foot 40 40 40 83 Yes Yes Yes Yes
M1208 Chronic postrheumatic arthropathy [Jaccoud], other specified site 40 40 40 83 Yes Yes Yes Yes
M1209 Chronic postrheumatic arthropathy [Jaccoud], multiple sites 40 40 40 83 Yes Yes Yes Yes
M300 Polyarteritis nodosa 40 40 40 84 Yes Yes Yes Yes
M301 Polyarteritis with lung involvement [Churg-Strauss] 40 40 40 84 Yes Yes Yes Yes
M302 Juvenile polyarteritis 40 40 40 84 Yes Yes Yes Yes
M303 Mucocutaneous lymph node syndrome [Kawasaki] 40 40 40 84 Yes Yes Yes Yes
M308 Other conditions related to polyarteritis nodosa 40 40 40 84 Yes Yes Yes Yes
M310 Hypersensitivity angiitis 40 40 40 84 Yes Yes Yes Yes
M311 Thrombotic microangiopathy 40 40 40 84 Yes Yes Yes Yes
M312 Lethal midline granuloma 40 40 40 84 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 139 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M3130 Wegener's granulomatosis without renal involvement 40 40 40 84 Yes Yes Yes Yes
M3131 Wegener's granulomatosis with renal involvement 40 40 40 84 Yes Yes Yes Yes
M314 Aortic arch syndrome [Takayasu] 40 40 40 84 Yes Yes Yes Yes
M315 Giant cell arteritis with polymyalgia rheumatica 40 40 40 84 Yes Yes Yes Yes
M316 Other giant cell arteritis 40 40 40 84 Yes Yes Yes Yes
M317 Microscopic polyangiitis 40 40 40 84 Yes Yes Yes Yes
M318 Other specified necrotizing vasculopathies 108 108 108 Yes Yes Yes No
M319 Necrotizing vasculopathy, unspecified 108 108 108 Yes Yes Yes No
M320 Drug-induced systemic lupus erythematosus 40 40 40 84 Yes Yes Yes Yes
M3210 Systemic lupus erythematosus, organ or system involvement unspecified 40 40 40 84 Yes Yes Yes Yes
M3211 Endocarditis in systemic lupus erythematosus 40 40 40 84 Yes Yes Yes Yes
M3212 Pericarditis in systemic lupus erythematosus 40 40 40 84 Yes Yes Yes Yes
M3213 Lung involvement in systemic lupus erythematosus 40 40 40 84 Yes Yes Yes Yes
M3213 Lung involvement in systemic lupus erythematosus 112 112 112 227 Yes Yes Yes Yes
M3214 Glomerular disease in systemic lupus erythematosus 40 40 40 84 Yes Yes Yes Yes
M3214 Glomerular disease in systemic lupus erythematosus 141 Yes -- -- --
M3215 Tubulo-interstitial nephropathy in systemic lupus erythematosus 40 40 40 84 Yes Yes Yes Yes
M3215 Tubulo-interstitial nephropathy in systemic lupus erythematosus 141 Yes -- -- --
M3219 Other organ or system involvement in systemic lupus erythematosus 40 40 40 84 Yes Yes Yes Yes
M328 Other forms of systemic lupus erythematosus 40 40 40 84 Yes Yes Yes Yes
M329 Systemic lupus erythematosus, unspecified 40 40 40 84 Yes Yes Yes Yes
M3300 Juvenile dermatomyositis, organ involvement unspecified 40 40 40 84 Yes Yes Yes Yes
M3301 Juvenile dermatomyositis with respiratory involvement 40 40 40 84 Yes Yes Yes Yes
M3301 Juvenile dermatomyositis with respiratory involvement 112 112 112 227 Yes Yes Yes Yes
M3302 Juvenile dermatomyositis with myopathy 40 40 40 84 Yes Yes Yes Yes
M3302 Juvenile dermatomyositis with myopathy 75 Yes -- -- --
M3303 Juvenile dermatomyositis without myopathy 40 40 40 84 Yes Yes Yes Yes
M3309 Juvenile dermatomyositis with other organ involvement 40 40 40 84 Yes Yes Yes Yes
M3310 Other dermatomyositis, organ involvement unspecified 40 40 40 84 Yes Yes Yes Yes
M3311 Other dermatomyositis with respiratory involvement 40 40 40 84 Yes Yes Yes Yes
M3311 Other dermatomyositis with respiratory involvement 112 112 112 227 Yes Yes Yes Yes
M3312 Other dermatomyositis with myopathy 40 40 40 84 Yes Yes Yes Yes
M3312 Other dermatomyositis with myopathy 75 Yes -- -- --
M3313 Other dermatomyositis without myopathy 40 40 40 84 Yes Yes Yes Yes
M3319 Other dermatomyositis with other organ involvement 40 40 40 84 Yes Yes Yes Yes
M3320 Polymyositis, organ involvement unspecified 40 40 40 84 Yes Yes Yes Yes
M3321 Polymyositis with respiratory involvement 40 40 40 84 Yes Yes Yes Yes
M3321 Polymyositis with respiratory involvement 112 112 112 227 Yes Yes Yes Yes
M3322 Polymyositis with myopathy 40 40 40 84 Yes Yes Yes Yes
M3322 Polymyositis with myopathy 75 Yes -- -- --
M3329 Polymyositis with other organ involvement 40 40 40 84 Yes Yes Yes Yes
M3390 Dermatopolymyositis, unspecified, organ involvement unspecified 40 40 40 84 Yes Yes Yes Yes
M3391 Dermatopolymyositis, unspecified with respiratory involvement 40 40 40 84 Yes Yes Yes Yes
M3391 Dermatopolymyositis, unspecified with respiratory involvement 112 112 112 227 Yes Yes Yes Yes
M3392 Dermatopolymyositis, unspecified with myopathy 40 40 40 84 Yes Yes Yes Yes
M3392 Dermatopolymyositis, unspecified with myopathy 75 Yes -- -- --
M3393 Dermatopolymyositis, unspecified without myopathy 40 40 40 84 Yes Yes Yes Yes
M3399 Dermatopolymyositis, unspecified with other organ involvement 40 40 40 84 Yes Yes Yes Yes
M340 Progressive systemic sclerosis 40 40 40 82 Yes Yes Yes Yes
M341 CR(E)ST syndrome 40 40 40 82 Yes Yes Yes Yes
M342 Systemic sclerosis induced by drug and chemical 40 40 40 82 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 140 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M3481 Systemic sclerosis with lung involvement 40 40 40 82 Yes Yes Yes Yes
M3481 Systemic sclerosis with lung involvement 112 112 112 227 Yes Yes Yes Yes
M3482 Systemic sclerosis with myopathy 40 40 40 82 Yes Yes Yes Yes
M3482 Systemic sclerosis with myopathy 75 Yes -- -- --
M3483 Systemic sclerosis with polyneuropathy 40 40 40 82 Yes Yes Yes Yes
M3483 Systemic sclerosis with polyneuropathy 75 75 75 159 Yes Yes Yes Yes
M3489 Other systemic sclerosis 40 40 40 82 Yes Yes Yes Yes
M349 Systemic sclerosis, unspecified 40 40 40 82 Yes Yes Yes Yes
M3500 Sicca syndrome, unspecified 40 40 40 84 Yes Yes Yes Yes
M3501 Sicca syndrome with keratoconjunctivitis 40 40 40 84 Yes Yes Yes Yes
M3502 Sicca syndrome with lung involvement 40 40 40 84 Yes Yes Yes Yes
M3502 Sicca syndrome with lung involvement 112 112 112 227 Yes Yes Yes Yes
M3503 Sicca syndrome with myopathy 40 40 40 84 Yes Yes Yes Yes
M3503 Sicca syndrome with myopathy 75 Yes -- -- --
M3504 Sicca syndrome with tubulo-interstitial nephropathy 40 40 40 84 Yes Yes Yes Yes
M3504 Sicca syndrome with tubulo-interstitial nephropathy 141 Yes -- -- --
M3509 Sicca syndrome with other organ involvement 40 40 40 84 Yes Yes Yes Yes
M351 Other overlap syndromes 40 40 40 84 Yes Yes Yes Yes
M352 Behcet's disease 40 40 40 83 Yes Yes Yes Yes
M353 Polymyalgia rheumatica 40 40 40 Yes Yes Yes No
M355 Multifocal fibrosclerosis 40 40 40 84 Yes Yes Yes Yes
M358 Other specified systemic involvement of connective tissue 40 40 40 84 Yes Yes Yes Yes
M359 Systemic involvement of connective tissue, unspecified 40 40 40 84 Yes Yes Yes Yes
M360 Dermato(poly)myositis in neoplastic disease 40 40 40 84 Yes Yes Yes Yes
M368 Systemic disorders of connective tissue in other diseases classified elsewhere 40 40 40 84 Yes Yes Yes Yes
M450 Ankylosing spondylitis of multiple sites in spine 40 40 40 84 Yes Yes Yes Yes
M451 Ankylosing spondylitis of occipito-atlanto-axial region 40 40 40 84 Yes Yes Yes Yes
M452 Ankylosing spondylitis of cervical region 40 40 40 84 Yes Yes Yes Yes
M453 Ankylosing spondylitis of cervicothoracic region 40 40 40 84 Yes Yes Yes Yes
M454 Ankylosing spondylitis of thoracic region 40 40 40 84 Yes Yes Yes Yes
M455 Ankylosing spondylitis of thoracolumbar region 40 40 40 84 Yes Yes Yes Yes
M456 Ankylosing spondylitis lumbar region 40 40 40 84 Yes Yes Yes Yes
M457 Ankylosing spondylitis of lumbosacral region 40 40 40 84 Yes Yes Yes Yes
M458 Ankylosing spondylitis sacral and sacrococcygeal region 40 40 40 84 Yes Yes Yes Yes
M459 Ankylosing spondylitis of unspecified sites in spine 40 40 40 84 Yes Yes Yes Yes
M4600 Spinal enthesopathy, site unspecified 40 40 40 84 Yes Yes Yes Yes
M4601 Spinal enthesopathy, occipito-atlanto-axial region 40 40 40 84 Yes Yes Yes Yes
M4602 Spinal enthesopathy, cervical region 40 40 40 84 Yes Yes Yes Yes
M4603 Spinal enthesopathy, cervicothoracic region 40 40 40 84 Yes Yes Yes Yes
M4604 Spinal enthesopathy, thoracic region 40 40 40 84 Yes Yes Yes Yes
M4605 Spinal enthesopathy, thoracolumbar region 40 40 40 84 Yes Yes Yes Yes
M4606 Spinal enthesopathy, lumbar region 40 40 40 84 Yes Yes Yes Yes
M4607 Spinal enthesopathy, lumbosacral region 40 40 40 84 Yes Yes Yes Yes
M4608 Spinal enthesopathy, sacral and sacrococcygeal region 40 40 40 84 Yes Yes Yes Yes
M4609 Spinal enthesopathy, multiple sites in spine 40 40 40 84 Yes Yes Yes Yes
M461 Sacroiliitis, not elsewhere classified 40 40 40 84 Yes Yes Yes Yes
M4620 Osteomyelitis of vertebra, site unspecified 39 39 39 Yes Yes Yes No
M4621 Osteomyelitis of vertebra, occipito-atlanto-axial region 39 39 39 Yes Yes Yes No
M4622 Osteomyelitis of vertebra, cervical region 39 39 39 Yes Yes Yes No
M4623 Osteomyelitis of vertebra, cervicothoracic region 39 39 39 Yes Yes Yes No
M4624 Osteomyelitis of vertebra, thoracic region 39 39 39 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 141 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M4625 Osteomyelitis of vertebra, thoracolumbar region 39 39 39 Yes Yes Yes No


M4626 Osteomyelitis of vertebra, lumbar region 39 39 39 Yes Yes Yes No
M4627 Osteomyelitis of vertebra, lumbosacral region 39 39 39 Yes Yes Yes No
M4628 Osteomyelitis of vertebra, sacral and sacrococcygeal region 39 39 39 Yes Yes Yes No
M4630 Infection of intervertebral disc (pyogenic), site unspecified 39 39 39 Yes Yes Yes No
M4631 Infection of intervertebral disc (pyogenic), occipito-atlanto-axial region 39 39 39 Yes Yes Yes No
M4632 Infection of intervertebral disc (pyogenic), cervical region 39 39 39 Yes Yes Yes No
M4633 Infection of intervertebral disc (pyogenic), cervicothoracic region 39 39 39 Yes Yes Yes No
M4634 Infection of intervertebral disc (pyogenic), thoracic region 39 39 39 Yes Yes Yes No
M4635 Infection of intervertebral disc (pyogenic), thoracolumbar region 39 39 39 Yes Yes Yes No
M4636 Infection of intervertebral disc (pyogenic), lumbar region 39 39 39 Yes Yes Yes No
M4637 Infection of intervertebral disc (pyogenic), lumbosacral region 39 39 39 Yes Yes Yes No
M4638 Infection of intervertebral disc (pyogenic), sacral and sacrococcygeal region 39 39 39 Yes Yes Yes No
M4639 Infection of intervertebral disc (pyogenic), multiple sites in spine 39 39 39 Yes Yes Yes No
M4650 Other infective spondylopathies, site unspecified 40 40 40 84 Yes Yes Yes Yes
M4651 Other infective spondylopathies, occipito-atlanto-axial region 40 40 40 84 Yes Yes Yes Yes
M4652 Other infective spondylopathies, cervical region 40 40 40 84 Yes Yes Yes Yes
M4653 Other infective spondylopathies, cervicothoracic region 40 40 40 84 Yes Yes Yes Yes
M4654 Other infective spondylopathies, thoracic region 40 40 40 84 Yes Yes Yes Yes
M4655 Other infective spondylopathies, thoracolumbar region 40 40 40 84 Yes Yes Yes Yes
M4656 Other infective spondylopathies, lumbar region 40 40 40 84 Yes Yes Yes Yes
M4657 Other infective spondylopathies, lumbosacral region 40 40 40 84 Yes Yes Yes Yes
M4658 Other infective spondylopathies, sacral and sacrococcygeal region 40 40 40 84 Yes Yes Yes Yes
M4659 Other infective spondylopathies, multiple sites in spine 40 40 40 84 Yes Yes Yes Yes
M4680 Other specified inflammatory spondylopathies, site unspecified 40 40 40 84 Yes Yes Yes Yes
M4681 Other specified inflammatory spondylopathies, occipito-atlanto-axial region 40 40 40 84 Yes Yes Yes Yes
M4682 Other specified inflammatory spondylopathies, cervical region 40 40 40 84 Yes Yes Yes Yes
M4683 Other specified inflammatory spondylopathies, cervicothoracic region 40 40 40 84 Yes Yes Yes Yes
M4684 Other specified inflammatory spondylopathies, thoracic region 40 40 40 84 Yes Yes Yes Yes
M4685 Other specified inflammatory spondylopathies, thoracolumbar region 40 40 40 84 Yes Yes Yes Yes
M4686 Other specified inflammatory spondylopathies, lumbar region 40 40 40 84 Yes Yes Yes Yes
M4687 Other specified inflammatory spondylopathies, lumbosacral region 40 40 40 84 Yes Yes Yes Yes
M4688 Other specified inflammatory spondylopathies, sacral and sacrococcygeal region 40 40 40 84 Yes Yes Yes Yes
M4689 Other specified inflammatory spondylopathies, multiple sites in spine 40 40 40 84 Yes Yes Yes Yes
M4690 Unspecified inflammatory spondylopathy, site unspecified 40 40 40 84 Yes Yes Yes Yes
M4691 Unspecified inflammatory spondylopathy, occipito-atlanto-axial region 40 40 40 84 Yes Yes Yes Yes
M4692 Unspecified inflammatory spondylopathy, cervical region 40 40 40 84 Yes Yes Yes Yes
M4693 Unspecified inflammatory spondylopathy, cervicothoracic region 40 40 40 84 Yes Yes Yes Yes
M4694 Unspecified inflammatory spondylopathy, thoracic region 40 40 40 84 Yes Yes Yes Yes
M4695 Unspecified inflammatory spondylopathy, thoracolumbar region 40 40 40 84 Yes Yes Yes Yes
M4696 Unspecified inflammatory spondylopathy, lumbar region 40 40 40 84 Yes Yes Yes Yes
M4697 Unspecified inflammatory spondylopathy, lumbosacral region 40 40 40 84 Yes Yes Yes Yes
M4698 Unspecified inflammatory spondylopathy, sacral and sacrococcygeal region 40 40 40 84 Yes Yes Yes Yes
M4699 Unspecified inflammatory spondylopathy, multiple sites in spine 40 40 40 84 Yes Yes Yes Yes
M4850XA Collapsed vertebra, not elsewhere classified, site unspecified, initial encounter for fracture 169 169 169 87 Yes Yes Yes Yes
M4851XA Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, initial encounter for 169 169 169 87 Yes Yes Yes Yes
fracture
M4852XA Collapsed vertebra, not elsewhere classified, cervical region, initial encounter for fracture 169 169 169 87 Yes Yes Yes Yes
M4853XA Collapsed vertebra, not elsewhere classified, cervicothoracic region, initial encounter for fracture 169 169 169 87 Yes Yes Yes Yes
M4854XA Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture 169 169 169 87 Yes Yes Yes Yes
M4855XA Collapsed vertebra, not elsewhere classified, thoracolumbar region, initial encounter for fracture 169 169 169 87 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 142 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M4856XA Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture 169 169 169 87 Yes Yes Yes Yes
M4857XA Collapsed vertebra, not elsewhere classified, lumbosacral region, initial encounter for fracture 169 169 169 87 Yes Yes Yes Yes
M4858XA Collapsed vertebra, not elsewhere classified, sacral and sacrococcygeal region, initial encounter for 169 169 169 87 Yes Yes Yes Yes
fracture
M488X1 Other specified spondylopathies, occipito-atlanto-axial region 40 40 40 84 Yes Yes Yes Yes
M488X2 Other specified spondylopathies, cervical region 40 40 40 84 Yes Yes Yes Yes
M488X3 Other specified spondylopathies, cervicothoracic region 40 40 40 84 Yes Yes Yes Yes
M488X4 Other specified spondylopathies, thoracic region 40 40 40 84 Yes Yes Yes Yes
M488X5 Other specified spondylopathies, thoracolumbar region 40 40 40 84 Yes Yes Yes Yes
M488X6 Other specified spondylopathies, lumbar region 40 40 40 84 Yes Yes Yes Yes
M488X7 Other specified spondylopathies, lumbosacral region 40 40 40 84 Yes Yes Yes Yes
M488X8 Other specified spondylopathies, sacral and sacrococcygeal region 40 40 40 84 Yes Yes Yes Yes
M488X9 Other specified spondylopathies, site unspecified 40 40 40 84 Yes Yes Yes Yes
M4980 Spondylopathy in diseases classified elsewhere, site unspecified 40 40 40 84 Yes Yes Yes Yes
M4981 Spondylopathy in diseases classified elsewhere, occipito-atlanto-axial region 40 40 40 84 Yes Yes Yes Yes
M4982 Spondylopathy in diseases classified elsewhere, cervical region 40 40 40 84 Yes Yes Yes Yes
M4983 Spondylopathy in diseases classified elsewhere, cervicothoracic region 40 40 40 84 Yes Yes Yes Yes
M4984 Spondylopathy in diseases classified elsewhere, thoracic region 40 40 40 84 Yes Yes Yes Yes
M4985 Spondylopathy in diseases classified elsewhere, thoracolumbar region 40 40 40 84 Yes Yes Yes Yes
M4986 Spondylopathy in diseases classified elsewhere, lumbar region 40 40 40 84 Yes Yes Yes Yes
M4987 Spondylopathy in diseases classified elsewhere, lumbosacral region 40 40 40 84 Yes Yes Yes Yes
M4988 Spondylopathy in diseases classified elsewhere, sacral and sacrococcygeal region 40 40 40 84 Yes Yes Yes Yes
M4989 Spondylopathy in diseases classified elsewhere, multiple sites in spine 40 40 40 84 Yes Yes Yes Yes
M726 Necrotizing fasciitis 39 39 39 Yes Yes Yes No
M8000XA Age-related osteoporosis with current pathological fracture, unspecified site, initial encounter for 87 No No No Yes
fracture
M80011A Age-related osteoporosis with current pathological fracture, right shoulder, initial encounter for 87 No No No Yes
fracture
M80012A Age-related osteoporosis with current pathological fracture, left shoulder, initial encounter for 87 No No No Yes
fracture
M80019A Age-related osteoporosis with current pathological fracture, unspecified shoulder, initial encounter 87 No No No Yes
for fracture
M80021A Age-related osteoporosis with current pathological fracture, right humerus, initial encounter for 87 No No No Yes
fracture
M80022A Age-related osteoporosis with current pathological fracture, left humerus, initial encounter for 87 No No No Yes
fracture
M80029A Age-related osteoporosis with current pathological fracture, unspecified humerus, initial encounter 87 No No No Yes
for fracture
M80031A Age-related osteoporosis with current pathological fracture, right forearm, initial encounter for 87 No No No Yes
fracture
M80032A Age-related osteoporosis with current pathological fracture, left forearm, initial encounter for 87 No No No Yes
fracture
M80039A Age-related osteoporosis with current pathological fracture, unspecified forearm, initial encounter 87 No No No Yes
for fracture
M80041A Age-related osteoporosis with current pathological fracture, right hand, initial encounter for fracture 87 No No No Yes
M80042A Age-related osteoporosis with current pathological fracture, left hand, initial encounter for fracture 87 No No No Yes
M80049A Age-related osteoporosis with current pathological fracture, unspecified hand, initial encounter for 87 No No No Yes
fracture
M80051A Age-related osteoporosis with current pathological fracture, right femur, initial encounter for 170 170 170 87 Yes Yes Yes Yes
fracture
M80052A Age-related osteoporosis with current pathological fracture, left femur, initial encounter for fracture 170 170 170 87 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 143 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M80059A Age-related osteoporosis with current pathological fracture, unspecified femur, initial encounter for 170 170 170 87 Yes Yes Yes Yes
fracture
M80061A Age-related osteoporosis with current pathological fracture, right lower leg, initial encounter for 87 No No No Yes
fracture
M80062A Age-related osteoporosis with current pathological fracture, left lower leg, initial encounter for 87 No No No Yes
fracture
M80069A Age-related osteoporosis with current pathological fracture, unspecified lower leg, initial encounter 87 No No No Yes
for fracture
M80071A Age-related osteoporosis with current pathological fracture, right ankle and foot, initial encounter 87 No No No Yes
for fracture
M80072A Age-related osteoporosis with current pathological fracture, left ankle and foot, initial encounter for 87 No No No Yes
fracture
M80079A Age-related osteoporosis with current pathological fracture, unspecified ankle and foot, initial 87 No No No Yes
encounter for fracture
M8008XA Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for 169 169 169 87 Yes Yes Yes Yes
fracture
M800AXA Age-related osteoporosis with current pathological fracture, other site, initial encounter for fracture 87 No No No Yes
M8080XA Other osteoporosis with current pathological fracture, unspecified site, initial encounter for fracture 87 No No No Yes
M80811A Other osteoporosis with current pathological fracture, right shoulder, initial encounter for fracture 87 No No No Yes
M80812A Other osteoporosis with current pathological fracture, left shoulder, initial encounter for fracture 87 No No No Yes
M80819A Other osteoporosis with current pathological fracture, unspecified shoulder, initial encounter for 87 No No No Yes
fracture
M80821A Other osteoporosis with current pathological fracture, right humerus, initial encounter for fracture 87 No No No Yes
M80822A Other osteoporosis with current pathological fracture, left humerus, initial encounter for fracture 87 No No No Yes
M80829A Other osteoporosis with current pathological fracture, unspecified humerus, initial encounter for 87 No No No Yes
fracture
M80831A Other osteoporosis with current pathological fracture, right forearm, initial encounter for fracture 87 No No No Yes
M80832A Other osteoporosis with current pathological fracture, left forearm, initial encounter for fracture 87 No No No Yes
M80839A Other osteoporosis with current pathological fracture, unspecified forearm, initial encounter for 87 No No No Yes
fracture
M80841A Other osteoporosis with current pathological fracture, right hand, initial encounter for fracture 87 No No No Yes
M80842A Other osteoporosis with current pathological fracture, left hand, initial encounter for fracture 87 No No No Yes
M80849A Other osteoporosis with current pathological fracture, unspecified hand, initial encounter for 87 No No No Yes
fracture
M80851A Other osteoporosis with current pathological fracture, right femur, initial encounter for fracture 170 170 170 87 Yes Yes Yes Yes
M80852A Other osteoporosis with current pathological fracture, left femur, initial encounter for fracture 170 170 170 87 Yes Yes Yes Yes
M80859A Other osteoporosis with current pathological fracture, unspecified femur, initial encounter for 170 170 170 87 Yes Yes Yes Yes
fracture
M80861A Other osteoporosis with current pathological fracture, right lower leg, initial encounter for fracture 87 No No No Yes
M80862A Other osteoporosis with current pathological fracture, left lower leg, initial encounter for fracture 87 No No No Yes
M80869A Other osteoporosis with current pathological fracture, unspecified lower leg, initial encounter for 87 No No No Yes
fracture
M80871A Other osteoporosis with current pathological fracture, right ankle and foot, initial encounter for 87 No No No Yes
fracture
M80872A Other osteoporosis with current pathological fracture, left ankle and foot, initial encounter for 87 No No No Yes
fracture
M80879A Other osteoporosis with current pathological fracture, unspecified ankle and foot, initial encounter 87 No No No Yes
for fracture
M8088XA Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture 169 169 169 87 Yes Yes Yes Yes
M808AXA Other osteoporosis with current pathological fracture, other site, initial encounter for fracture 87 No No No Yes
M810 Age-related osteoporosis without current pathological fracture 87 No No No Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 144 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M816 Localized osteoporosis [Lequesne] 87 No No No Yes


M818 Other osteoporosis without current pathological fracture 87 No No No Yes
M830 Puerperal osteomalacia 87 No No No Yes
M831 Senile osteomalacia 87 No No No Yes
M832 Adult osteomalacia due to malabsorption 87 No No No Yes
M833 Adult osteomalacia due to malnutrition 87 No No No Yes
M834 Aluminum bone disease 87 No No No Yes
M835 Other drug-induced osteomalacia in adults 87 No No No Yes
M838 Other adult osteomalacia 87 No No No Yes
M839 Adult osteomalacia, unspecified 87 No No No Yes
M8440XA Pathological fracture, unspecified site, initial encounter for fracture 87 No No No Yes
M84411A Pathological fracture, right shoulder, initial encounter for fracture 87 No No No Yes
M84412A Pathological fracture, left shoulder, initial encounter for fracture 87 No No No Yes
M84419A Pathological fracture, unspecified shoulder, initial encounter for fracture 87 No No No Yes
M84421A Pathological fracture, right humerus, initial encounter for fracture 87 No No No Yes
M84422A Pathological fracture, left humerus, initial encounter for fracture 87 No No No Yes
M84429A Pathological fracture, unspecified humerus, initial encounter for fracture 87 No No No Yes
M84431A Pathological fracture, right ulna, initial encounter for fracture 87 No No No Yes
M84432A Pathological fracture, left ulna, initial encounter for fracture 87 No No No Yes
M84433A Pathological fracture, right radius, initial encounter for fracture 87 No No No Yes
M84434A Pathological fracture, left radius, initial encounter for fracture 87 No No No Yes
M84439A Pathological fracture, unspecified ulna and radius, initial encounter for fracture 87 No No No Yes
M84441A Pathological fracture, right hand, initial encounter for fracture 87 No No No Yes
M84442A Pathological fracture, left hand, initial encounter for fracture 87 No No No Yes
M84443A Pathological fracture, unspecified hand, initial encounter for fracture 87 No No No Yes
M84444A Pathological fracture, right finger(s), initial encounter for fracture 87 No No No Yes
M84445A Pathological fracture, left finger(s), initial encounter for fracture 87 No No No Yes
M84446A Pathological fracture, unspecified finger(s), initial encounter for fracture 87 No No No Yes
M84451A Pathological fracture, right femur, initial encounter for fracture 170 170 170 87 Yes Yes Yes Yes
M84452A Pathological fracture, left femur, initial encounter for fracture 170 170 170 87 Yes Yes Yes Yes
M84453A Pathological fracture, unspecified femur, initial encounter for fracture 170 170 170 87 Yes Yes Yes Yes
M84454A Pathological fracture, pelvis, initial encounter for fracture 87 No No No Yes
M84459A Pathological fracture, hip, unspecified, initial encounter for fracture 170 170 170 87 Yes Yes Yes Yes
M84461A Pathological fracture, right tibia, initial encounter for fracture 87 No No No Yes
M84462A Pathological fracture, left tibia, initial encounter for fracture 87 No No No Yes
M84463A Pathological fracture, right fibula, initial encounter for fracture 87 No No No Yes
M84464A Pathological fracture, left fibula, initial encounter for fracture 87 No No No Yes
M84469A Pathological fracture, unspecified tibia and fibula, initial encounter for fracture 87 No No No Yes
M84471A Pathological fracture, right ankle, initial encounter for fracture 87 No No No Yes
M84472A Pathological fracture, left ankle, initial encounter for fracture 87 No No No Yes
M84473A Pathological fracture, unspecified ankle, initial encounter for fracture 87 No No No Yes
M84474A Pathological fracture, right foot, initial encounter for fracture 87 No No No Yes
M84475A Pathological fracture, left foot, initial encounter for fracture 87 No No No Yes
M84476A Pathological fracture, unspecified foot, initial encounter for fracture 87 No No No Yes
M84477A Pathological fracture, right toe(s), initial encounter for fracture 87 No No No Yes
M84478A Pathological fracture, left toe(s), initial encounter for fracture 87 No No No Yes
M84479A Pathological fracture, unspecified toe(s), initial encounter for fracture 87 No No No Yes
M8448XA Pathological fracture, other site, initial encounter for fracture 87 No No No Yes
M8450XA Pathological fracture in neoplastic disease, unspecified site, initial encounter for fracture 87 No No No Yes
M84511A Pathological fracture in neoplastic disease, right shoulder, initial encounter for fracture 87 No No No Yes
M84512A Pathological fracture in neoplastic disease, left shoulder, initial encounter for fracture 87 No No No Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 145 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M84519A Pathological fracture in neoplastic disease, unspecified shoulder, initial encounter for fracture 87 No No No Yes
M84521A Pathological fracture in neoplastic disease, right humerus, initial encounter for fracture 87 No No No Yes
M84522A Pathological fracture in neoplastic disease, left humerus, initial encounter for fracture 87 No No No Yes
M84529A Pathological fracture in neoplastic disease, unspecified humerus, initial encounter for fracture 87 No No No Yes
M84531A Pathological fracture in neoplastic disease, right ulna, initial encounter for fracture 87 No No No Yes
M84532A Pathological fracture in neoplastic disease, left ulna, initial encounter for fracture 87 No No No Yes
M84533A Pathological fracture in neoplastic disease, right radius, initial encounter for fracture 87 No No No Yes
M84534A Pathological fracture in neoplastic disease, left radius, initial encounter for fracture 87 No No No Yes
M84539A Pathological fracture in neoplastic disease, unspecified ulna and radius, initial encounter for fracture 87 No No No Yes
M84541A Pathological fracture in neoplastic disease, right hand, initial encounter for fracture 87 No No No Yes
M84542A Pathological fracture in neoplastic disease, left hand, initial encounter for fracture 87 No No No Yes
M84549A Pathological fracture in neoplastic disease, unspecified hand, initial encounter for fracture 87 No No No Yes
M84550A Pathological fracture in neoplastic disease, pelvis, initial encounter for fracture 87 No No No Yes
M84551A Pathological fracture in neoplastic disease, right femur, initial encounter for fracture 170 170 170 87 Yes Yes Yes Yes
M84552A Pathological fracture in neoplastic disease, left femur, initial encounter for fracture 170 170 170 87 Yes Yes Yes Yes
M84553A Pathological fracture in neoplastic disease, unspecified femur, initial encounter for fracture 170 170 170 87 Yes Yes Yes Yes
M84559A Pathological fracture in neoplastic disease, hip, unspecified, initial encounter for fracture 170 170 170 87 Yes Yes Yes Yes
M84561A Pathological fracture in neoplastic disease, right tibia, initial encounter for fracture 87 No No No Yes
M84562A Pathological fracture in neoplastic disease, left tibia, initial encounter for fracture 87 No No No Yes
M84563A Pathological fracture in neoplastic disease, right fibula, initial encounter for fracture 87 No No No Yes
M84564A Pathological fracture in neoplastic disease, left fibula, initial encounter for fracture 87 No No No Yes
M84569A Pathological fracture in neoplastic disease, unspecified tibia and fibula, initial encounter for fracture 87 No No No Yes
M84571A Pathological fracture in neoplastic disease, right ankle, initial encounter for fracture 87 No No No Yes
M84572A Pathological fracture in neoplastic disease, left ankle, initial encounter for fracture 87 No No No Yes
M84573A Pathological fracture in neoplastic disease, unspecified ankle, initial encounter for fracture 87 No No No Yes
M84574A Pathological fracture in neoplastic disease, right foot, initial encounter for fracture 87 No No No Yes
M84575A Pathological fracture in neoplastic disease, left foot, initial encounter for fracture 87 No No No Yes
M84576A Pathological fracture in neoplastic disease, unspecified foot, initial encounter for fracture 87 No No No Yes
M8458XA Pathological fracture in neoplastic disease, other specified site, initial encounter for fracture 87 No No No Yes
M8460XA Pathological fracture in other disease, unspecified site, initial encounter for fracture 87 No No No Yes
M84611A Pathological fracture in other disease, right shoulder, initial encounter for fracture 87 No No No Yes
M84612A Pathological fracture in other disease, left shoulder, initial encounter for fracture 87 No No No Yes
M84619A Pathological fracture in other disease, unspecified shoulder, initial encounter for fracture 87 No No No Yes
M84621A Pathological fracture in other disease, right humerus, initial encounter for fracture 87 No No No Yes
M84622A Pathological fracture in other disease, left humerus, initial encounter for fracture 87 No No No Yes
M84629A Pathological fracture in other disease, unspecified humerus, initial encounter for fracture 87 No No No Yes
M84631A Pathological fracture in other disease, right ulna, initial encounter for fracture 87 No No No Yes
M84632A Pathological fracture in other disease, left ulna, initial encounter for fracture 87 No No No Yes
M84633A Pathological fracture in other disease, right radius, initial encounter for fracture 87 No No No Yes
M84634A Pathological fracture in other disease, left radius, initial encounter for fracture 87 No No No Yes
M84639A Pathological fracture in other disease, unspecified ulna and radius, initial encounter for fracture 87 No No No Yes
M84641A Pathological fracture in other disease, right hand, initial encounter for fracture 87 No No No Yes
M84642A Pathological fracture in other disease, left hand, initial encounter for fracture 87 No No No Yes
M84649A Pathological fracture in other disease, unspecified hand, initial encounter for fracture 87 No No No Yes
M84650A Pathological fracture in other disease, pelvis, initial encounter for fracture 87 No No No Yes
M84651A Pathological fracture in other disease, right femur, initial encounter for fracture 170 170 170 87 Yes Yes Yes Yes
M84652A Pathological fracture in other disease, left femur, initial encounter for fracture 170 170 170 87 Yes Yes Yes Yes
M84653A Pathological fracture in other disease, unspecified femur, initial encounter for fracture 170 170 170 87 Yes Yes Yes Yes
M84659A Pathological fracture in other disease, hip, unspecified, initial encounter for fracture 170 170 170 87 Yes Yes Yes Yes
M84661A Pathological fracture in other disease, right tibia, initial encounter for fracture 87 No No No Yes
M84662A Pathological fracture in other disease, left tibia, initial encounter for fracture 87 No No No Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 146 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M84663A Pathological fracture in other disease, right fibula, initial encounter for fracture 87 No No No Yes
M84664A Pathological fracture in other disease, left fibula, initial encounter for fracture 87 No No No Yes
M84669A Pathological fracture in other disease, unspecified tibia and fibula, initial encounter for fracture 87 No No No Yes
M84671A Pathological fracture in other disease, right ankle, initial encounter for fracture 87 No No No Yes
M84672A Pathological fracture in other disease, left ankle, initial encounter for fracture 87 No No No Yes
M84673A Pathological fracture in other disease, unspecified ankle, initial encounter for fracture 87 No No No Yes
M84674A Pathological fracture in other disease, right foot, initial encounter for fracture 87 No No No Yes
M84675A Pathological fracture in other disease, left foot, initial encounter for fracture 87 No No No Yes
M84676A Pathological fracture in other disease, unspecified foot, initial encounter for fracture 87 No No No Yes
M8468XA Pathological fracture in other disease, other site, initial encounter for fracture 87 No No No Yes
M84754A Complete transverse atypical femoral fracture, right leg, initial encounter for fracture 170 170 170 Yes Yes Yes No
M84755A Complete transverse atypical femoral fracture, left leg, initial encounter for fracture 170 170 170 Yes Yes Yes No
M84756A Complete transverse atypical femoral fracture, unspecified leg, initial encounter for fracture 170 170 170 Yes Yes Yes No
M84757A Complete oblique atypical femoral fracture, right leg, initial encounter for fracture 170 170 170 Yes Yes Yes No
M84758A Complete oblique atypical femoral fracture, left leg, initial encounter for fracture 170 170 170 Yes Yes Yes No
M84759A Complete oblique atypical femoral fracture, unspecified leg, initial encounter for fracture 170 170 170 Yes Yes Yes No
M8600 Acute hematogenous osteomyelitis, unspecified site 39 39 39 Yes Yes Yes No
M86011 Acute hematogenous osteomyelitis, right shoulder 39 39 39 Yes Yes Yes No
M86012 Acute hematogenous osteomyelitis, left shoulder 39 39 39 Yes Yes Yes No
M86019 Acute hematogenous osteomyelitis, unspecified shoulder 39 39 39 Yes Yes Yes No
M86021 Acute hematogenous osteomyelitis, right humerus 39 39 39 Yes Yes Yes No
M86022 Acute hematogenous osteomyelitis, left humerus 39 39 39 Yes Yes Yes No
M86029 Acute hematogenous osteomyelitis, unspecified humerus 39 39 39 Yes Yes Yes No
M86031 Acute hematogenous osteomyelitis, right radius and ulna 39 39 39 Yes Yes Yes No
M86032 Acute hematogenous osteomyelitis, left radius and ulna 39 39 39 Yes Yes Yes No
M86039 Acute hematogenous osteomyelitis, unspecified radius and ulna 39 39 39 Yes Yes Yes No
M86041 Acute hematogenous osteomyelitis, right hand 39 39 39 Yes Yes Yes No
M86042 Acute hematogenous osteomyelitis, left hand 39 39 39 Yes Yes Yes No
M86049 Acute hematogenous osteomyelitis, unspecified hand 39 39 39 Yes Yes Yes No
M86051 Acute hematogenous osteomyelitis, right femur 39 39 39 Yes Yes Yes No
M86052 Acute hematogenous osteomyelitis, left femur 39 39 39 Yes Yes Yes No
M86059 Acute hematogenous osteomyelitis, unspecified femur 39 39 39 Yes Yes Yes No
M86061 Acute hematogenous osteomyelitis, right tibia and fibula 39 39 39 Yes Yes Yes No
M86062 Acute hematogenous osteomyelitis, left tibia and fibula 39 39 39 Yes Yes Yes No
M86069 Acute hematogenous osteomyelitis, unspecified tibia and fibula 39 39 39 Yes Yes Yes No
M86071 Acute hematogenous osteomyelitis, right ankle and foot 39 39 39 Yes Yes Yes No
M86072 Acute hematogenous osteomyelitis, left ankle and foot 39 39 39 Yes Yes Yes No
M86079 Acute hematogenous osteomyelitis, unspecified ankle and foot 39 39 39 Yes Yes Yes No
M8608 Acute hematogenous osteomyelitis, other sites 39 39 39 Yes Yes Yes No
M8609 Acute hematogenous osteomyelitis, multiple sites 39 39 39 Yes Yes Yes No
M8610 Other acute osteomyelitis, unspecified site 39 39 39 Yes Yes Yes No
M86111 Other acute osteomyelitis, right shoulder 39 39 39 Yes Yes Yes No
M86112 Other acute osteomyelitis, left shoulder 39 39 39 Yes Yes Yes No
M86119 Other acute osteomyelitis, unspecified shoulder 39 39 39 Yes Yes Yes No
M86121 Other acute osteomyelitis, right humerus 39 39 39 Yes Yes Yes No
M86122 Other acute osteomyelitis, left humerus 39 39 39 Yes Yes Yes No
M86129 Other acute osteomyelitis, unspecified humerus 39 39 39 Yes Yes Yes No
M86131 Other acute osteomyelitis, right radius and ulna 39 39 39 Yes Yes Yes No
M86132 Other acute osteomyelitis, left radius and ulna 39 39 39 Yes Yes Yes No
M86139 Other acute osteomyelitis, unspecified radius and ulna 39 39 39 Yes Yes Yes No
M86141 Other acute osteomyelitis, right hand 39 39 39 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 147 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M86142 Other acute osteomyelitis, left hand 39 39 39 Yes Yes Yes No


M86149 Other acute osteomyelitis, unspecified hand 39 39 39 Yes Yes Yes No
M86151 Other acute osteomyelitis, right femur 39 39 39 Yes Yes Yes No
M86152 Other acute osteomyelitis, left femur 39 39 39 Yes Yes Yes No
M86159 Other acute osteomyelitis, unspecified femur 39 39 39 Yes Yes Yes No
M86161 Other acute osteomyelitis, right tibia and fibula 39 39 39 Yes Yes Yes No
M86162 Other acute osteomyelitis, left tibia and fibula 39 39 39 Yes Yes Yes No
M86169 Other acute osteomyelitis, unspecified tibia and fibula 39 39 39 Yes Yes Yes No
M86171 Other acute osteomyelitis, right ankle and foot 39 39 39 Yes Yes Yes No
M86172 Other acute osteomyelitis, left ankle and foot 39 39 39 Yes Yes Yes No
M86179 Other acute osteomyelitis, unspecified ankle and foot 39 39 39 Yes Yes Yes No
M8618 Other acute osteomyelitis, other site 39 39 39 Yes Yes Yes No
M8619 Other acute osteomyelitis, multiple sites 39 39 39 Yes Yes Yes No
M8620 Subacute osteomyelitis, unspecified site 39 39 39 Yes Yes Yes No
M86211 Subacute osteomyelitis, right shoulder 39 39 39 Yes Yes Yes No
M86212 Subacute osteomyelitis, left shoulder 39 39 39 Yes Yes Yes No
M86219 Subacute osteomyelitis, unspecified shoulder 39 39 39 Yes Yes Yes No
M86221 Subacute osteomyelitis, right humerus 39 39 39 Yes Yes Yes No
M86222 Subacute osteomyelitis, left humerus 39 39 39 Yes Yes Yes No
M86229 Subacute osteomyelitis, unspecified humerus 39 39 39 Yes Yes Yes No
M86231 Subacute osteomyelitis, right radius and ulna 39 39 39 Yes Yes Yes No
M86232 Subacute osteomyelitis, left radius and ulna 39 39 39 Yes Yes Yes No
M86239 Subacute osteomyelitis, unspecified radius and ulna 39 39 39 Yes Yes Yes No
M86241 Subacute osteomyelitis, right hand 39 39 39 Yes Yes Yes No
M86242 Subacute osteomyelitis, left hand 39 39 39 Yes Yes Yes No
M86249 Subacute osteomyelitis, unspecified hand 39 39 39 Yes Yes Yes No
M86251 Subacute osteomyelitis, right femur 39 39 39 Yes Yes Yes No
M86252 Subacute osteomyelitis, left femur 39 39 39 Yes Yes Yes No
M86259 Subacute osteomyelitis, unspecified femur 39 39 39 Yes Yes Yes No
M86261 Subacute osteomyelitis, right tibia and fibula 39 39 39 Yes Yes Yes No
M86262 Subacute osteomyelitis, left tibia and fibula 39 39 39 Yes Yes Yes No
M86269 Subacute osteomyelitis, unspecified tibia and fibula 39 39 39 Yes Yes Yes No
M86271 Subacute osteomyelitis, right ankle and foot 39 39 39 Yes Yes Yes No
M86272 Subacute osteomyelitis, left ankle and foot 39 39 39 Yes Yes Yes No
M86279 Subacute osteomyelitis, unspecified ankle and foot 39 39 39 Yes Yes Yes No
M8628 Subacute osteomyelitis, other site 39 39 39 Yes Yes Yes No
M8629 Subacute osteomyelitis, multiple sites 39 39 39 Yes Yes Yes No
M8630 Chronic multifocal osteomyelitis, unspecified site 39 39 39 Yes Yes Yes No
M86311 Chronic multifocal osteomyelitis, right shoulder 39 39 39 Yes Yes Yes No
M86312 Chronic multifocal osteomyelitis, left shoulder 39 39 39 Yes Yes Yes No
M86319 Chronic multifocal osteomyelitis, unspecified shoulder 39 39 39 Yes Yes Yes No
M86321 Chronic multifocal osteomyelitis, right humerus 39 39 39 Yes Yes Yes No
M86322 Chronic multifocal osteomyelitis, left humerus 39 39 39 Yes Yes Yes No
M86329 Chronic multifocal osteomyelitis, unspecified humerus 39 39 39 Yes Yes Yes No
M86331 Chronic multifocal osteomyelitis, right radius and ulna 39 39 39 Yes Yes Yes No
M86332 Chronic multifocal osteomyelitis, left radius and ulna 39 39 39 Yes Yes Yes No
M86339 Chronic multifocal osteomyelitis, unspecified radius and ulna 39 39 39 Yes Yes Yes No
M86341 Chronic multifocal osteomyelitis, right hand 39 39 39 Yes Yes Yes No
M86342 Chronic multifocal osteomyelitis, left hand 39 39 39 Yes Yes Yes No
M86349 Chronic multifocal osteomyelitis, unspecified hand 39 39 39 Yes Yes Yes No
M86351 Chronic multifocal osteomyelitis, right femur 39 39 39 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 148 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M86352 Chronic multifocal osteomyelitis, left femur 39 39 39 Yes Yes Yes No


M86359 Chronic multifocal osteomyelitis, unspecified femur 39 39 39 Yes Yes Yes No
M86361 Chronic multifocal osteomyelitis, right tibia and fibula 39 39 39 Yes Yes Yes No
M86362 Chronic multifocal osteomyelitis, left tibia and fibula 39 39 39 Yes Yes Yes No
M86369 Chronic multifocal osteomyelitis, unspecified tibia and fibula 39 39 39 Yes Yes Yes No
M86371 Chronic multifocal osteomyelitis, right ankle and foot 39 39 39 Yes Yes Yes No
M86372 Chronic multifocal osteomyelitis, left ankle and foot 39 39 39 Yes Yes Yes No
M86379 Chronic multifocal osteomyelitis, unspecified ankle and foot 39 39 39 Yes Yes Yes No
M8638 Chronic multifocal osteomyelitis, other site 39 39 39 Yes Yes Yes No
M8639 Chronic multifocal osteomyelitis, multiple sites 39 39 39 Yes Yes Yes No
M8640 Chronic osteomyelitis with draining sinus, unspecified site 39 39 39 Yes Yes Yes No
M86411 Chronic osteomyelitis with draining sinus, right shoulder 39 39 39 Yes Yes Yes No
M86412 Chronic osteomyelitis with draining sinus, left shoulder 39 39 39 Yes Yes Yes No
M86419 Chronic osteomyelitis with draining sinus, unspecified shoulder 39 39 39 Yes Yes Yes No
M86421 Chronic osteomyelitis with draining sinus, right humerus 39 39 39 Yes Yes Yes No
M86422 Chronic osteomyelitis with draining sinus, left humerus 39 39 39 Yes Yes Yes No
M86429 Chronic osteomyelitis with draining sinus, unspecified humerus 39 39 39 Yes Yes Yes No
M86431 Chronic osteomyelitis with draining sinus, right radius and ulna 39 39 39 Yes Yes Yes No
M86432 Chronic osteomyelitis with draining sinus, left radius and ulna 39 39 39 Yes Yes Yes No
M86439 Chronic osteomyelitis with draining sinus, unspecified radius and ulna 39 39 39 Yes Yes Yes No
M86441 Chronic osteomyelitis with draining sinus, right hand 39 39 39 Yes Yes Yes No
M86442 Chronic osteomyelitis with draining sinus, left hand 39 39 39 Yes Yes Yes No
M86449 Chronic osteomyelitis with draining sinus, unspecified hand 39 39 39 Yes Yes Yes No
M86451 Chronic osteomyelitis with draining sinus, right femur 39 39 39 Yes Yes Yes No
M86452 Chronic osteomyelitis with draining sinus, left femur 39 39 39 Yes Yes Yes No
M86459 Chronic osteomyelitis with draining sinus, unspecified femur 39 39 39 Yes Yes Yes No
M86461 Chronic osteomyelitis with draining sinus, right tibia and fibula 39 39 39 Yes Yes Yes No
M86462 Chronic osteomyelitis with draining sinus, left tibia and fibula 39 39 39 Yes Yes Yes No
M86469 Chronic osteomyelitis with draining sinus, unspecified tibia and fibula 39 39 39 Yes Yes Yes No
M86471 Chronic osteomyelitis with draining sinus, right ankle and foot 39 39 39 Yes Yes Yes No
M86472 Chronic osteomyelitis with draining sinus, left ankle and foot 39 39 39 Yes Yes Yes No
M86479 Chronic osteomyelitis with draining sinus, unspecified ankle and foot 39 39 39 Yes Yes Yes No
M8648 Chronic osteomyelitis with draining sinus, other site 39 39 39 Yes Yes Yes No
M8649 Chronic osteomyelitis with draining sinus, multiple sites 39 39 39 Yes Yes Yes No
M8650 Other chronic hematogenous osteomyelitis, unspecified site 39 39 39 Yes Yes Yes No
M86511 Other chronic hematogenous osteomyelitis, right shoulder 39 39 39 Yes Yes Yes No
M86512 Other chronic hematogenous osteomyelitis, left shoulder 39 39 39 Yes Yes Yes No
M86519 Other chronic hematogenous osteomyelitis, unspecified shoulder 39 39 39 Yes Yes Yes No
M86521 Other chronic hematogenous osteomyelitis, right humerus 39 39 39 Yes Yes Yes No
M86522 Other chronic hematogenous osteomyelitis, left humerus 39 39 39 Yes Yes Yes No
M86529 Other chronic hematogenous osteomyelitis, unspecified humerus 39 39 39 Yes Yes Yes No
M86531 Other chronic hematogenous osteomyelitis, right radius and ulna 39 39 39 Yes Yes Yes No
M86532 Other chronic hematogenous osteomyelitis, left radius and ulna 39 39 39 Yes Yes Yes No
M86539 Other chronic hematogenous osteomyelitis, unspecified radius and ulna 39 39 39 Yes Yes Yes No
M86541 Other chronic hematogenous osteomyelitis, right hand 39 39 39 Yes Yes Yes No
M86542 Other chronic hematogenous osteomyelitis, left hand 39 39 39 Yes Yes Yes No
M86549 Other chronic hematogenous osteomyelitis, unspecified hand 39 39 39 Yes Yes Yes No
M86551 Other chronic hematogenous osteomyelitis, right femur 39 39 39 Yes Yes Yes No
M86552 Other chronic hematogenous osteomyelitis, left femur 39 39 39 Yes Yes Yes No
M86559 Other chronic hematogenous osteomyelitis, unspecified femur 39 39 39 Yes Yes Yes No
M86561 Other chronic hematogenous osteomyelitis, right tibia and fibula 39 39 39 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 149 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M86562 Other chronic hematogenous osteomyelitis, left tibia and fibula 39 39 39 Yes Yes Yes No
M86569 Other chronic hematogenous osteomyelitis, unspecified tibia and fibula 39 39 39 Yes Yes Yes No
M86571 Other chronic hematogenous osteomyelitis, right ankle and foot 39 39 39 Yes Yes Yes No
M86572 Other chronic hematogenous osteomyelitis, left ankle and foot 39 39 39 Yes Yes Yes No
M86579 Other chronic hematogenous osteomyelitis, unspecified ankle and foot 39 39 39 Yes Yes Yes No
M8658 Other chronic hematogenous osteomyelitis, other site 39 39 39 Yes Yes Yes No
M8659 Other chronic hematogenous osteomyelitis, multiple sites 39 39 39 Yes Yes Yes No
M8660 Other chronic osteomyelitis, unspecified site 39 39 39 Yes Yes Yes No
M86611 Other chronic osteomyelitis, right shoulder 39 39 39 Yes Yes Yes No
M86612 Other chronic osteomyelitis, left shoulder 39 39 39 Yes Yes Yes No
M86619 Other chronic osteomyelitis, unspecified shoulder 39 39 39 Yes Yes Yes No
M86621 Other chronic osteomyelitis, right humerus 39 39 39 Yes Yes Yes No
M86622 Other chronic osteomyelitis, left humerus 39 39 39 Yes Yes Yes No
M86629 Other chronic osteomyelitis, unspecified humerus 39 39 39 Yes Yes Yes No
M86631 Other chronic osteomyelitis, right radius and ulna 39 39 39 Yes Yes Yes No
M86632 Other chronic osteomyelitis, left radius and ulna 39 39 39 Yes Yes Yes No
M86639 Other chronic osteomyelitis, unspecified radius and ulna 39 39 39 Yes Yes Yes No
M86641 Other chronic osteomyelitis, right hand 39 39 39 Yes Yes Yes No
M86642 Other chronic osteomyelitis, left hand 39 39 39 Yes Yes Yes No
M86649 Other chronic osteomyelitis, unspecified hand 39 39 39 Yes Yes Yes No
M86651 Other chronic osteomyelitis, right thigh 39 39 39 Yes Yes Yes No
M86652 Other chronic osteomyelitis, left thigh 39 39 39 Yes Yes Yes No
M86659 Other chronic osteomyelitis, unspecified thigh 39 39 39 Yes Yes Yes No
M86661 Other chronic osteomyelitis, right tibia and fibula 39 39 39 Yes Yes Yes No
M86662 Other chronic osteomyelitis, left tibia and fibula 39 39 39 Yes Yes Yes No
M86669 Other chronic osteomyelitis, unspecified tibia and fibula 39 39 39 Yes Yes Yes No
M86671 Other chronic osteomyelitis, right ankle and foot 39 39 39 Yes Yes Yes No
M86672 Other chronic osteomyelitis, left ankle and foot 39 39 39 Yes Yes Yes No
M86679 Other chronic osteomyelitis, unspecified ankle and foot 39 39 39 Yes Yes Yes No
M8668 Other chronic osteomyelitis, other site 39 39 39 Yes Yes Yes No
M8669 Other chronic osteomyelitis, multiple sites 39 39 39 Yes Yes Yes No
M868X0 Other osteomyelitis, multiple sites 39 39 39 Yes Yes Yes No
M868X1 Other osteomyelitis, shoulder 39 39 39 Yes Yes Yes No
M868X2 Other osteomyelitis, upper arm 39 39 39 Yes Yes Yes No
M868X3 Other osteomyelitis, forearm 39 39 39 Yes Yes Yes No
M868X4 Other osteomyelitis, hand 39 39 39 Yes Yes Yes No
M868X5 Other osteomyelitis, thigh 39 39 39 Yes Yes Yes No
M868X6 Other osteomyelitis, lower leg 39 39 39 Yes Yes Yes No
M868X7 Other osteomyelitis, ankle and foot 39 39 39 Yes Yes Yes No
M868X8 Other osteomyelitis, other site 39 39 39 Yes Yes Yes No
M868X9 Other osteomyelitis, unspecified sites 39 39 39 Yes Yes Yes No
M869 Osteomyelitis, unspecified 39 39 39 Yes Yes Yes No
M8700 Idiopathic aseptic necrosis of unspecified bone 39 39 39 80 Yes Yes Yes Yes
M87011 Idiopathic aseptic necrosis of right shoulder 39 39 39 80 Yes Yes Yes Yes
M87012 Idiopathic aseptic necrosis of left shoulder 39 39 39 80 Yes Yes Yes Yes
M87019 Idiopathic aseptic necrosis of unspecified shoulder 39 39 39 80 Yes Yes Yes Yes
M87021 Idiopathic aseptic necrosis of right humerus 39 39 39 80 Yes Yes Yes Yes
M87022 Idiopathic aseptic necrosis of left humerus 39 39 39 80 Yes Yes Yes Yes
M87029 Idiopathic aseptic necrosis of unspecified humerus 39 39 39 80 Yes Yes Yes Yes
M87031 Idiopathic aseptic necrosis of right radius 39 39 39 80 Yes Yes Yes Yes
M87032 Idiopathic aseptic necrosis of left radius 39 39 39 80 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 150 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M87033 Idiopathic aseptic necrosis of unspecified radius 39 39 39 80 Yes Yes Yes Yes
M87034 Idiopathic aseptic necrosis of right ulna 39 39 39 80 Yes Yes Yes Yes
M87035 Idiopathic aseptic necrosis of left ulna 39 39 39 80 Yes Yes Yes Yes
M87036 Idiopathic aseptic necrosis of unspecified ulna 39 39 39 80 Yes Yes Yes Yes
M87037 Idiopathic aseptic necrosis of right carpus 39 39 39 80 Yes Yes Yes Yes
M87038 Idiopathic aseptic necrosis of left carpus 39 39 39 80 Yes Yes Yes Yes
M87039 Idiopathic aseptic necrosis of unspecified carpus 39 39 39 80 Yes Yes Yes Yes
M87041 Idiopathic aseptic necrosis of right hand 39 39 39 80 Yes Yes Yes Yes
M87042 Idiopathic aseptic necrosis of left hand 39 39 39 80 Yes Yes Yes Yes
M87043 Idiopathic aseptic necrosis of unspecified hand 39 39 39 80 Yes Yes Yes Yes
M87044 Idiopathic aseptic necrosis of right finger(s) 39 39 39 80 Yes Yes Yes Yes
M87045 Idiopathic aseptic necrosis of left finger(s) 39 39 39 80 Yes Yes Yes Yes
M87046 Idiopathic aseptic necrosis of unspecified finger(s) 39 39 39 80 Yes Yes Yes Yes
M87050 Idiopathic aseptic necrosis of pelvis 39 39 39 80 Yes Yes Yes Yes
M87051 Idiopathic aseptic necrosis of right femur 39 39 39 80 Yes Yes Yes Yes
M87052 Idiopathic aseptic necrosis of left femur 39 39 39 80 Yes Yes Yes Yes
M87059 Idiopathic aseptic necrosis of unspecified femur 39 39 39 80 Yes Yes Yes Yes
M87061 Idiopathic aseptic necrosis of right tibia 39 39 39 80 Yes Yes Yes Yes
M87062 Idiopathic aseptic necrosis of left tibia 39 39 39 80 Yes Yes Yes Yes
M87063 Idiopathic aseptic necrosis of unspecified tibia 39 39 39 80 Yes Yes Yes Yes
M87064 Idiopathic aseptic necrosis of right fibula 39 39 39 80 Yes Yes Yes Yes
M87065 Idiopathic aseptic necrosis of left fibula 39 39 39 80 Yes Yes Yes Yes
M87066 Idiopathic aseptic necrosis of unspecified fibula 39 39 39 80 Yes Yes Yes Yes
M87071 Idiopathic aseptic necrosis of right ankle 39 39 39 80 Yes Yes Yes Yes
M87072 Idiopathic aseptic necrosis of left ankle 39 39 39 80 Yes Yes Yes Yes
M87073 Idiopathic aseptic necrosis of unspecified ankle 39 39 39 80 Yes Yes Yes Yes
M87074 Idiopathic aseptic necrosis of right foot 39 39 39 80 Yes Yes Yes Yes
M87075 Idiopathic aseptic necrosis of left foot 39 39 39 80 Yes Yes Yes Yes
M87076 Idiopathic aseptic necrosis of unspecified foot 39 39 39 80 Yes Yes Yes Yes
M87077 Idiopathic aseptic necrosis of right toe(s) 39 39 39 80 Yes Yes Yes Yes
M87078 Idiopathic aseptic necrosis of left toe(s) 39 39 39 80 Yes Yes Yes Yes
M87079 Idiopathic aseptic necrosis of unspecified toe(s) 39 39 39 80 Yes Yes Yes Yes
M8708 Idiopathic aseptic necrosis of bone, other site 39 39 39 80 Yes Yes Yes Yes
M8709 Idiopathic aseptic necrosis of bone, multiple sites 39 39 39 80 Yes Yes Yes Yes
M8710 Osteonecrosis due to drugs, unspecified bone 39 39 39 80 Yes Yes Yes Yes
M87111 Osteonecrosis due to drugs, right shoulder 39 39 39 80 Yes Yes Yes Yes
M87112 Osteonecrosis due to drugs, left shoulder 39 39 39 80 Yes Yes Yes Yes
M87119 Osteonecrosis due to drugs, unspecified shoulder 39 39 39 80 Yes Yes Yes Yes
M87121 Osteonecrosis due to drugs, right humerus 39 39 39 80 Yes Yes Yes Yes
M87122 Osteonecrosis due to drugs, left humerus 39 39 39 80 Yes Yes Yes Yes
M87129 Osteonecrosis due to drugs, unspecified humerus 39 39 39 80 Yes Yes Yes Yes
M87131 Osteonecrosis due to drugs of right radius 39 39 39 80 Yes Yes Yes Yes
M87132 Osteonecrosis due to drugs of left radius 39 39 39 80 Yes Yes Yes Yes
M87133 Osteonecrosis due to drugs of unspecified radius 39 39 39 80 Yes Yes Yes Yes
M87134 Osteonecrosis due to drugs of right ulna 39 39 39 80 Yes Yes Yes Yes
M87135 Osteonecrosis due to drugs of left ulna 39 39 39 80 Yes Yes Yes Yes
M87136 Osteonecrosis due to drugs of unspecified ulna 39 39 39 80 Yes Yes Yes Yes
M87137 Osteonecrosis due to drugs of right carpus 39 39 39 80 Yes Yes Yes Yes
M87138 Osteonecrosis due to drugs of left carpus 39 39 39 80 Yes Yes Yes Yes
M87139 Osteonecrosis due to drugs of unspecified carpus 39 39 39 80 Yes Yes Yes Yes
M87141 Osteonecrosis due to drugs, right hand 39 39 39 80 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 151 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M87142 Osteonecrosis due to drugs, left hand 39 39 39 80 Yes Yes Yes Yes
M87143 Osteonecrosis due to drugs, unspecified hand 39 39 39 80 Yes Yes Yes Yes
M87144 Osteonecrosis due to drugs, right finger(s) 39 39 39 80 Yes Yes Yes Yes
M87145 Osteonecrosis due to drugs, left finger(s) 39 39 39 80 Yes Yes Yes Yes
M87146 Osteonecrosis due to drugs, unspecified finger(s) 39 39 39 80 Yes Yes Yes Yes
M87150 Osteonecrosis due to drugs, pelvis 39 39 39 80 Yes Yes Yes Yes
M87151 Osteonecrosis due to drugs, right femur 39 39 39 80 Yes Yes Yes Yes
M87152 Osteonecrosis due to drugs, left femur 39 39 39 80 Yes Yes Yes Yes
M87159 Osteonecrosis due to drugs, unspecified femur 39 39 39 80 Yes Yes Yes Yes
M87161 Osteonecrosis due to drugs, right tibia 39 39 39 80 Yes Yes Yes Yes
M87162 Osteonecrosis due to drugs, left tibia 39 39 39 80 Yes Yes Yes Yes
M87163 Osteonecrosis due to drugs, unspecified tibia 39 39 39 80 Yes Yes Yes Yes
M87164 Osteonecrosis due to drugs, right fibula 39 39 39 80 Yes Yes Yes Yes
M87165 Osteonecrosis due to drugs, left fibula 39 39 39 80 Yes Yes Yes Yes
M87166 Osteonecrosis due to drugs, unspecified fibula 39 39 39 80 Yes Yes Yes Yes
M87171 Osteonecrosis due to drugs, right ankle 39 39 39 80 Yes Yes Yes Yes
M87172 Osteonecrosis due to drugs, left ankle 39 39 39 80 Yes Yes Yes Yes
M87173 Osteonecrosis due to drugs, unspecified ankle 39 39 39 80 Yes Yes Yes Yes
M87174 Osteonecrosis due to drugs, right foot 39 39 39 80 Yes Yes Yes Yes
M87175 Osteonecrosis due to drugs, left foot 39 39 39 80 Yes Yes Yes Yes
M87176 Osteonecrosis due to drugs, unspecified foot 39 39 39 80 Yes Yes Yes Yes
M87177 Osteonecrosis due to drugs, right toe(s) 39 39 39 80 Yes Yes Yes Yes
M87178 Osteonecrosis due to drugs, left toe(s) 39 39 39 80 Yes Yes Yes Yes
M87179 Osteonecrosis due to drugs, unspecified toe(s) 39 39 39 80 Yes Yes Yes Yes
M87180 Osteonecrosis due to drugs, jaw 39 39 39 80 Yes Yes Yes Yes
M87188 Osteonecrosis due to drugs, other site 39 39 39 80 Yes Yes Yes Yes
M8719 Osteonecrosis due to drugs, multiple sites 39 39 39 80 Yes Yes Yes Yes
M8720 Osteonecrosis due to previous trauma, unspecified bone 39 39 39 80 Yes Yes Yes Yes
M87211 Osteonecrosis due to previous trauma, right shoulder 39 39 39 80 Yes Yes Yes Yes
M87212 Osteonecrosis due to previous trauma, left shoulder 39 39 39 80 Yes Yes Yes Yes
M87219 Osteonecrosis due to previous trauma, unspecified shoulder 39 39 39 80 Yes Yes Yes Yes
M87221 Osteonecrosis due to previous trauma, right humerus 39 39 39 80 Yes Yes Yes Yes
M87222 Osteonecrosis due to previous trauma, left humerus 39 39 39 80 Yes Yes Yes Yes
M87229 Osteonecrosis due to previous trauma, unspecified humerus 39 39 39 80 Yes Yes Yes Yes
M87231 Osteonecrosis due to previous trauma of right radius 39 39 39 80 Yes Yes Yes Yes
M87232 Osteonecrosis due to previous trauma of left radius 39 39 39 80 Yes Yes Yes Yes
M87233 Osteonecrosis due to previous trauma of unspecified radius 39 39 39 80 Yes Yes Yes Yes
M87234 Osteonecrosis due to previous trauma of right ulna 39 39 39 80 Yes Yes Yes Yes
M87235 Osteonecrosis due to previous trauma of left ulna 39 39 39 80 Yes Yes Yes Yes
M87236 Osteonecrosis due to previous trauma of unspecified ulna 39 39 39 80 Yes Yes Yes Yes
M87237 Osteonecrosis due to previous trauma of right carpus 39 39 39 80 Yes Yes Yes Yes
M87238 Osteonecrosis due to previous trauma of left carpus 39 39 39 80 Yes Yes Yes Yes
M87239 Osteonecrosis due to previous trauma of unspecified carpus 39 39 39 80 Yes Yes Yes Yes
M87241 Osteonecrosis due to previous trauma, right hand 39 39 39 80 Yes Yes Yes Yes
M87242 Osteonecrosis due to previous trauma, left hand 39 39 39 80 Yes Yes Yes Yes
M87243 Osteonecrosis due to previous trauma, unspecified hand 39 39 39 80 Yes Yes Yes Yes
M87244 Osteonecrosis due to previous trauma, right finger(s) 39 39 39 80 Yes Yes Yes Yes
M87245 Osteonecrosis due to previous trauma, left finger(s) 39 39 39 80 Yes Yes Yes Yes
M87246 Osteonecrosis due to previous trauma, unspecified finger(s) 39 39 39 80 Yes Yes Yes Yes
M87250 Osteonecrosis due to previous trauma, pelvis 39 39 39 80 Yes Yes Yes Yes
M87251 Osteonecrosis due to previous trauma, right femur 39 39 39 80 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 152 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M87252 Osteonecrosis due to previous trauma, left femur 39 39 39 80 Yes Yes Yes Yes
M87256 Osteonecrosis due to previous trauma, unspecified femur 39 39 39 80 Yes Yes Yes Yes
M87261 Osteonecrosis due to previous trauma, right tibia 39 39 39 80 Yes Yes Yes Yes
M87262 Osteonecrosis due to previous trauma, left tibia 39 39 39 80 Yes Yes Yes Yes
M87263 Osteonecrosis due to previous trauma, unspecified tibia 39 39 39 80 Yes Yes Yes Yes
M87264 Osteonecrosis due to previous trauma, right fibula 39 39 39 80 Yes Yes Yes Yes
M87265 Osteonecrosis due to previous trauma, left fibula 39 39 39 80 Yes Yes Yes Yes
M87266 Osteonecrosis due to previous trauma, unspecified fibula 39 39 39 80 Yes Yes Yes Yes
M87271 Osteonecrosis due to previous trauma, right ankle 39 39 39 80 Yes Yes Yes Yes
M87272 Osteonecrosis due to previous trauma, left ankle 39 39 39 80 Yes Yes Yes Yes
M87273 Osteonecrosis due to previous trauma, unspecified ankle 39 39 39 80 Yes Yes Yes Yes
M87274 Osteonecrosis due to previous trauma, right foot 39 39 39 80 Yes Yes Yes Yes
M87275 Osteonecrosis due to previous trauma, left foot 39 39 39 80 Yes Yes Yes Yes
M87276 Osteonecrosis due to previous trauma, unspecified foot 39 39 39 80 Yes Yes Yes Yes
M87277 Osteonecrosis due to previous trauma, right toe(s) 39 39 39 80 Yes Yes Yes Yes
M87278 Osteonecrosis due to previous trauma, left toe(s) 39 39 39 80 Yes Yes Yes Yes
M87279 Osteonecrosis due to previous trauma, unspecified toe(s) 39 39 39 80 Yes Yes Yes Yes
M8728 Osteonecrosis due to previous trauma, other site 39 39 39 80 Yes Yes Yes Yes
M8729 Osteonecrosis due to previous trauma, multiple sites 39 39 39 80 Yes Yes Yes Yes
M8730 Other secondary osteonecrosis, unspecified bone 39 39 39 80 Yes Yes Yes Yes
M87311 Other secondary osteonecrosis, right shoulder 39 39 39 80 Yes Yes Yes Yes
M87312 Other secondary osteonecrosis, left shoulder 39 39 39 80 Yes Yes Yes Yes
M87319 Other secondary osteonecrosis, unspecified shoulder 39 39 39 80 Yes Yes Yes Yes
M87321 Other secondary osteonecrosis, right humerus 39 39 39 80 Yes Yes Yes Yes
M87322 Other secondary osteonecrosis, left humerus 39 39 39 80 Yes Yes Yes Yes
M87329 Other secondary osteonecrosis, unspecified humerus 39 39 39 80 Yes Yes Yes Yes
M87331 Other secondary osteonecrosis of right radius 39 39 39 80 Yes Yes Yes Yes
M87332 Other secondary osteonecrosis of left radius 39 39 39 80 Yes Yes Yes Yes
M87333 Other secondary osteonecrosis of unspecified radius 39 39 39 80 Yes Yes Yes Yes
M87334 Other secondary osteonecrosis of right ulna 39 39 39 80 Yes Yes Yes Yes
M87335 Other secondary osteonecrosis of left ulna 39 39 39 80 Yes Yes Yes Yes
M87336 Other secondary osteonecrosis of unspecified ulna 39 39 39 80 Yes Yes Yes Yes
M87337 Other secondary osteonecrosis of right carpus 39 39 39 80 Yes Yes Yes Yes
M87338 Other secondary osteonecrosis of left carpus 39 39 39 80 Yes Yes Yes Yes
M87339 Other secondary osteonecrosis of unspecified carpus 39 39 39 80 Yes Yes Yes Yes
M87341 Other secondary osteonecrosis, right hand 39 39 39 80 Yes Yes Yes Yes
M87342 Other secondary osteonecrosis, left hand 39 39 39 80 Yes Yes Yes Yes
M87343 Other secondary osteonecrosis, unspecified hand 39 39 39 80 Yes Yes Yes Yes
M87344 Other secondary osteonecrosis, right finger(s) 39 39 39 80 Yes Yes Yes Yes
M87345 Other secondary osteonecrosis, left finger(s) 39 39 39 80 Yes Yes Yes Yes
M87346 Other secondary osteonecrosis, unspecified finger(s) 39 39 39 80 Yes Yes Yes Yes
M87350 Other secondary osteonecrosis, pelvis 39 39 39 80 Yes Yes Yes Yes
M87351 Other secondary osteonecrosis, right femur 39 39 39 80 Yes Yes Yes Yes
M87352 Other secondary osteonecrosis, left femur 39 39 39 80 Yes Yes Yes Yes
M87353 Other secondary osteonecrosis, unspecified femur 39 39 39 80 Yes Yes Yes Yes
M87361 Other secondary osteonecrosis, right tibia 39 39 39 80 Yes Yes Yes Yes
M87362 Other secondary osteonecrosis, left tibia 39 39 39 80 Yes Yes Yes Yes
M87363 Other secondary osteonecrosis, unspecified tibia 39 39 39 80 Yes Yes Yes Yes
M87364 Other secondary osteonecrosis, right fibula 39 39 39 80 Yes Yes Yes Yes
M87365 Other secondary osteonecrosis, left fibula 39 39 39 80 Yes Yes Yes Yes
M87366 Other secondary osteonecrosis, unspecified fibula 39 39 39 80 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 153 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M87371 Other secondary osteonecrosis, right ankle 39 39 39 80 Yes Yes Yes Yes
M87372 Other secondary osteonecrosis, left ankle 39 39 39 80 Yes Yes Yes Yes
M87373 Other secondary osteonecrosis, unspecified ankle 39 39 39 80 Yes Yes Yes Yes
M87374 Other secondary osteonecrosis, right foot 39 39 39 80 Yes Yes Yes Yes
M87375 Other secondary osteonecrosis, left foot 39 39 39 80 Yes Yes Yes Yes
M87376 Other secondary osteonecrosis, unspecified foot 39 39 39 80 Yes Yes Yes Yes
M87377 Other secondary osteonecrosis, right toe(s) 39 39 39 80 Yes Yes Yes Yes
M87378 Other secondary osteonecrosis, left toe(s) 39 39 39 80 Yes Yes Yes Yes
M87379 Other secondary osteonecrosis, unspecified toe(s) 39 39 39 80 Yes Yes Yes Yes
M8738 Other secondary osteonecrosis, other site 39 39 39 80 Yes Yes Yes Yes
M8739 Other secondary osteonecrosis, multiple sites 39 39 39 80 Yes Yes Yes Yes
M8780 Other osteonecrosis, unspecified bone 39 39 39 80 Yes Yes Yes Yes
M87811 Other osteonecrosis, right shoulder 39 39 39 80 Yes Yes Yes Yes
M87812 Other osteonecrosis, left shoulder 39 39 39 80 Yes Yes Yes Yes
M87819 Other osteonecrosis, unspecified shoulder 39 39 39 80 Yes Yes Yes Yes
M87821 Other osteonecrosis, right humerus 39 39 39 80 Yes Yes Yes Yes
M87822 Other osteonecrosis, left humerus 39 39 39 80 Yes Yes Yes Yes
M87829 Other osteonecrosis, unspecified humerus 39 39 39 80 Yes Yes Yes Yes
M87831 Other osteonecrosis of right radius 39 39 39 80 Yes Yes Yes Yes
M87832 Other osteonecrosis of left radius 39 39 39 80 Yes Yes Yes Yes
M87833 Other osteonecrosis of unspecified radius 39 39 39 80 Yes Yes Yes Yes
M87834 Other osteonecrosis of right ulna 39 39 39 80 Yes Yes Yes Yes
M87835 Other osteonecrosis of left ulna 39 39 39 80 Yes Yes Yes Yes
M87836 Other osteonecrosis of unspecified ulna 39 39 39 80 Yes Yes Yes Yes
M87837 Other osteonecrosis of right carpus 39 39 39 80 Yes Yes Yes Yes
M87838 Other osteonecrosis of left carpus 39 39 39 80 Yes Yes Yes Yes
M87839 Other osteonecrosis of unspecified carpus 39 39 39 80 Yes Yes Yes Yes
M87841 Other osteonecrosis, right hand 39 39 39 80 Yes Yes Yes Yes
M87842 Other osteonecrosis, left hand 39 39 39 80 Yes Yes Yes Yes
M87843 Other osteonecrosis, unspecified hand 39 39 39 80 Yes Yes Yes Yes
M87844 Other osteonecrosis, right finger(s) 39 39 39 80 Yes Yes Yes Yes
M87845 Other osteonecrosis, left finger(s) 39 39 39 80 Yes Yes Yes Yes
M87849 Other osteonecrosis, unspecified finger(s) 39 39 39 80 Yes Yes Yes Yes
M87850 Other osteonecrosis, pelvis 39 39 39 80 Yes Yes Yes Yes
M87851 Other osteonecrosis, right femur 39 39 39 80 Yes Yes Yes Yes
M87852 Other osteonecrosis, left femur 39 39 39 80 Yes Yes Yes Yes
M87859 Other osteonecrosis, unspecified femur 39 39 39 80 Yes Yes Yes Yes
M87861 Other osteonecrosis, right tibia 39 39 39 80 Yes Yes Yes Yes
M87862 Other osteonecrosis, left tibia 39 39 39 80 Yes Yes Yes Yes
M87863 Other osteonecrosis, unspecified tibia 39 39 39 80 Yes Yes Yes Yes
M87864 Other osteonecrosis, right fibula 39 39 39 80 Yes Yes Yes Yes
M87865 Other osteonecrosis, left fibula 39 39 39 80 Yes Yes Yes Yes
M87869 Other osteonecrosis, unspecified fibula 39 39 39 80 Yes Yes Yes Yes
M87871 Other osteonecrosis, right ankle 39 39 39 80 Yes Yes Yes Yes
M87872 Other osteonecrosis, left ankle 39 39 39 80 Yes Yes Yes Yes
M87873 Other osteonecrosis, unspecified ankle 39 39 39 80 Yes Yes Yes Yes
M87874 Other osteonecrosis, right foot 39 39 39 80 Yes Yes Yes Yes
M87875 Other osteonecrosis, left foot 39 39 39 80 Yes Yes Yes Yes
M87876 Other osteonecrosis, unspecified foot 39 39 39 80 Yes Yes Yes Yes
M87877 Other osteonecrosis, right toe(s) 39 39 39 80 Yes Yes Yes Yes
M87878 Other osteonecrosis, left toe(s) 39 39 39 80 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 154 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M87879 Other osteonecrosis, unspecified toe(s) 39 39 39 80 Yes Yes Yes Yes


M8788 Other osteonecrosis, other site 39 39 39 80 Yes Yes Yes Yes
M8789 Other osteonecrosis, multiple sites 39 39 39 80 Yes Yes Yes Yes
M879 Osteonecrosis, unspecified 39 39 39 80 Yes Yes Yes Yes
M8960 Osteopathy after poliomyelitis, unspecified site 39 39 39 Yes Yes Yes No
M89611 Osteopathy after poliomyelitis, right shoulder 39 39 39 Yes Yes Yes No
M89612 Osteopathy after poliomyelitis, left shoulder 39 39 39 Yes Yes Yes No
M89619 Osteopathy after poliomyelitis, unspecified shoulder 39 39 39 Yes Yes Yes No
M89621 Osteopathy after poliomyelitis, right upper arm 39 39 39 Yes Yes Yes No
M89622 Osteopathy after poliomyelitis, left upper arm 39 39 39 Yes Yes Yes No
M89629 Osteopathy after poliomyelitis, unspecified upper arm 39 39 39 Yes Yes Yes No
M89631 Osteopathy after poliomyelitis, right forearm 39 39 39 Yes Yes Yes No
M89632 Osteopathy after poliomyelitis, left forearm 39 39 39 Yes Yes Yes No
M89639 Osteopathy after poliomyelitis, unspecified forearm 39 39 39 Yes Yes Yes No
M89641 Osteopathy after poliomyelitis, right hand 39 39 39 Yes Yes Yes No
M89642 Osteopathy after poliomyelitis, left hand 39 39 39 Yes Yes Yes No
M89649 Osteopathy after poliomyelitis, unspecified hand 39 39 39 Yes Yes Yes No
M89651 Osteopathy after poliomyelitis, right thigh 39 39 39 Yes Yes Yes No
M89652 Osteopathy after poliomyelitis, left thigh 39 39 39 Yes Yes Yes No
M89659 Osteopathy after poliomyelitis, unspecified thigh 39 39 39 Yes Yes Yes No
M89661 Osteopathy after poliomyelitis, right lower leg 39 39 39 Yes Yes Yes No
M89662 Osteopathy after poliomyelitis, left lower leg 39 39 39 Yes Yes Yes No
M89669 Osteopathy after poliomyelitis, unspecified lower leg 39 39 39 Yes Yes Yes No
M89671 Osteopathy after poliomyelitis, right ankle and foot 39 39 39 Yes Yes Yes No
M89672 Osteopathy after poliomyelitis, left ankle and foot 39 39 39 Yes Yes Yes No
M89679 Osteopathy after poliomyelitis, unspecified ankle and foot 39 39 39 Yes Yes Yes No
M8968 Osteopathy after poliomyelitis, other site 39 39 39 Yes Yes Yes No
M8969 Osteopathy after poliomyelitis, multiple sites 39 39 39 Yes Yes Yes No
M9050 Osteonecrosis in diseases classified elsewhere, unspecified site 39 39 39 80 Yes Yes Yes Yes
M90511 Osteonecrosis in diseases classified elsewhere, right shoulder 39 39 39 80 Yes Yes Yes Yes
M90512 Osteonecrosis in diseases classified elsewhere, left shoulder 39 39 39 80 Yes Yes Yes Yes
M90519 Osteonecrosis in diseases classified elsewhere, unspecified shoulder 39 39 39 80 Yes Yes Yes Yes
M90521 Osteonecrosis in diseases classified elsewhere, right upper arm 39 39 39 80 Yes Yes Yes Yes
M90522 Osteonecrosis in diseases classified elsewhere, left upper arm 39 39 39 80 Yes Yes Yes Yes
M90529 Osteonecrosis in diseases classified elsewhere, unspecified upper arm 39 39 39 80 Yes Yes Yes Yes
M90531 Osteonecrosis in diseases classified elsewhere, right forearm 39 39 39 80 Yes Yes Yes Yes
M90532 Osteonecrosis in diseases classified elsewhere, left forearm 39 39 39 80 Yes Yes Yes Yes
M90539 Osteonecrosis in diseases classified elsewhere, unspecified forearm 39 39 39 80 Yes Yes Yes Yes
M90541 Osteonecrosis in diseases classified elsewhere, right hand 39 39 39 80 Yes Yes Yes Yes
M90542 Osteonecrosis in diseases classified elsewhere, left hand 39 39 39 80 Yes Yes Yes Yes
M90549 Osteonecrosis in diseases classified elsewhere, unspecified hand 39 39 39 80 Yes Yes Yes Yes
M90551 Osteonecrosis in diseases classified elsewhere, right thigh 39 39 39 80 Yes Yes Yes Yes
M90552 Osteonecrosis in diseases classified elsewhere, left thigh 39 39 39 80 Yes Yes Yes Yes
M90559 Osteonecrosis in diseases classified elsewhere, unspecified thigh 39 39 39 80 Yes Yes Yes Yes
M90561 Osteonecrosis in diseases classified elsewhere, right lower leg 39 39 39 80 Yes Yes Yes Yes
M90562 Osteonecrosis in diseases classified elsewhere, left lower leg 39 39 39 80 Yes Yes Yes Yes
M90569 Osteonecrosis in diseases classified elsewhere, unspecified lower leg 39 39 39 80 Yes Yes Yes Yes
M90571 Osteonecrosis in diseases classified elsewhere, right ankle and foot 39 39 39 80 Yes Yes Yes Yes
M90572 Osteonecrosis in diseases classified elsewhere, left ankle and foot 39 39 39 80 Yes Yes Yes Yes
M90579 Osteonecrosis in diseases classified elsewhere, unspecified ankle and foot 39 39 39 80 Yes Yes Yes Yes
M9058 Osteonecrosis in diseases classified elsewhere, other site 39 39 39 80 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 155 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

M9059 Osteonecrosis in diseases classified elsewhere, multiple sites 39 39 39 80 Yes Yes Yes Yes
M96621 Fracture of humerus following insertion of orthopedic implant, joint prosthesis, or bone plate, right 176 176 176 Yes Yes Yes No
arm
M96622 Fracture of humerus following insertion of orthopedic implant, joint prosthesis, or bone plate, left 176 176 176 Yes Yes Yes No
arm
M96629 Fracture of humerus following insertion of orthopedic implant, joint prosthesis, or bone plate, 176 176 176 Yes Yes Yes No
unspecified arm
M96631 Fracture of radius or ulna following insertion of orthopedic implant, joint prosthesis, or bone plate, 176 176 176 Yes Yes Yes No
right arm
M96632 Fracture of radius or ulna following insertion of orthopedic implant, joint prosthesis, or bone plate, 176 176 176 Yes Yes Yes No
left arm
M96639 Fracture of radius or ulna following insertion of orthopedic implant, joint prosthesis, or bone plate, 176 176 176 Yes Yes Yes No
unspecified arm
M9665 Fracture of pelvis following insertion of orthopedic implant, joint prosthesis, or bone plate 176 176 176 Yes Yes Yes No
M96661 Fracture of femur following insertion of orthopedic implant, joint prosthesis, or bone plate, right leg 176 176 176 Yes Yes Yes No
M96662 Fracture of femur following insertion of orthopedic implant, joint prosthesis, or bone plate, left leg 176 176 176 Yes Yes Yes No
M96669 Fracture of femur following insertion of orthopedic implant, joint prosthesis, or bone plate, 176 176 176 Yes Yes Yes No
unspecified leg
M96671 Fracture of tibia or fibula following insertion of orthopedic implant, joint prosthesis, or bone plate, 176 176 176 Yes Yes Yes No
right leg
M96672 Fracture of tibia or fibula following insertion of orthopedic implant, joint prosthesis, or bone plate, 176 176 176 Yes Yes Yes No
left leg
M96679 Fracture of tibia or fibula following insertion of orthopedic implant, joint prosthesis, or bone plate, 176 176 176 Yes Yes Yes No
unspecified leg
M9669 Fracture of other bone following insertion of orthopedic implant, joint prosthesis, or bone plate 176 176 176 Yes Yes Yes No
M9701XA Periprosthetic fracture around internal prosthetic right hip joint, initial encounter 170 170 170 Yes Yes Yes No
M9702XA Periprosthetic fracture around internal prosthetic left hip joint, initial encounter 170 170 170 Yes Yes Yes No
N000 Acute nephritic syndrome with minor glomerular abnormality 141 Yes No No No
N001 Acute nephritic syndrome with focal and segmental glomerular lesions 141 Yes No No No
N002 Acute nephritic syndrome with diffuse membranous glomerulonephritis 141 Yes No No No
N003 Acute nephritic syndrome with diffuse mesangial proliferative glomerulonephritis 141 Yes No No No
N004 Acute nephritic syndrome with diffuse endocapillary proliferative glomerulonephritis 141 Yes No No No
N005 Acute nephritic syndrome with diffuse mesangiocapillary glomerulonephritis 141 Yes No No No
N006 Acute nephritic syndrome with dense deposit disease 141 Yes No No No
N007 Acute nephritic syndrome with diffuse crescentic glomerulonephritis 141 Yes No No No
N008 Acute nephritic syndrome with other morphologic changes 141 Yes No No No
N009 Acute nephritic syndrome with unspecified morphologic changes 141 Yes No No No
N00A Acute nephritic syndrome with C3 glomerulonephritis 141 Yes No No No
N010 Rapidly progressive nephritic syndrome with minor glomerular abnormality 141 Yes No No No
N011 Rapidly progressive nephritic syndrome with focal and segmental glomerular lesions 141 Yes No No No
N012 Rapidly progressive nephritic syndrome with diffuse membranous glomerulonephritis 141 Yes No No No
N013 Rapidly progressive nephritic syndrome with diffuse mesangial proliferative glomerulonephritis 141 Yes No No No
N014 Rapidly progressive nephritic syndrome with diffuse endocapillary proliferative glomerulonephritis 141 Yes No No No
N015 Rapidly progressive nephritic syndrome with diffuse mesangiocapillary glomerulonephritis 141 Yes No No No
N016 Rapidly progressive nephritic syndrome with dense deposit disease 141 Yes No No No
N017 Rapidly progressive nephritic syndrome with diffuse crescentic glomerulonephritis 141 Yes No No No
N018 Rapidly progressive nephritic syndrome with other morphologic changes 141 Yes No No No
N019 Rapidly progressive nephritic syndrome with unspecified morphologic changes 141 Yes No No No
N01A Rapidly progressive nephritic syndrome with C3 glomerulonephritis 141 Yes No No No
N020 Recurrent and persistent hematuria with minor glomerular abnormality 141 Yes No No No
N021 Recurrent and persistent hematuria with focal and segmental glomerular lesions 141 Yes No No No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 156 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

N022 Recurrent and persistent hematuria with diffuse membranous glomerulonephritis 141 Yes No No No
N023 Recurrent and persistent hematuria with diffuse mesangial proliferative glomerulonephritis 141 Yes No No No
N024 Recurrent and persistent hematuria with diffuse endocapillary proliferative glomerulonephritis 141 Yes No No No
N025 Recurrent and persistent hematuria with diffuse mesangiocapillary glomerulonephritis 141 Yes No No No
N026 Recurrent and persistent hematuria with dense deposit disease 141 Yes No No No
N027 Recurrent and persistent hematuria with diffuse crescentic glomerulonephritis 141 Yes No No No
N028 Recurrent and persistent hematuria with other morphologic changes 141 Yes No No No
N029 Recurrent and persistent hematuria with unspecified morphologic changes 141 Yes No No No
N02A Recurrent and persistent hematuria with C3 glomerulonephritis 141 Yes No No No
N030 Chronic nephritic syndrome with minor glomerular abnormality 141 Yes No No No
N031 Chronic nephritic syndrome with focal and segmental glomerular lesions 141 Yes No No No
N032 Chronic nephritic syndrome with diffuse membranous glomerulonephritis 141 Yes No No No
N033 Chronic nephritic syndrome with diffuse mesangial proliferative glomerulonephritis 141 Yes No No No
N034 Chronic nephritic syndrome with diffuse endocapillary proliferative glomerulonephritis 141 Yes No No No
N035 Chronic nephritic syndrome with diffuse mesangiocapillary glomerulonephritis 141 Yes No No No
N036 Chronic nephritic syndrome with dense deposit disease 141 Yes No No No
N037 Chronic nephritic syndrome with diffuse crescentic glomerulonephritis 141 Yes No No No
N038 Chronic nephritic syndrome with other morphologic changes 141 Yes No No No
N039 Chronic nephritic syndrome with unspecified morphologic changes 141 Yes No No No
N03A Chronic nephritic syndrome with C3 glomerulonephritis 141 Yes No No No
N040 Nephrotic syndrome with minor glomerular abnormality 141 Yes No No No
N041 Nephrotic syndrome with focal and segmental glomerular lesions 141 Yes No No No
N042 Nephrotic syndrome with diffuse membranous glomerulonephritis 141 Yes No No No
N043 Nephrotic syndrome with diffuse mesangial proliferative glomerulonephritis 141 Yes No No No
N044 Nephrotic syndrome with diffuse endocapillary proliferative glomerulonephritis 141 Yes No No No
N045 Nephrotic syndrome with diffuse mesangiocapillary glomerulonephritis 141 Yes No No No
N046 Nephrotic syndrome with dense deposit disease 141 Yes No No No
N047 Nephrotic syndrome with diffuse crescentic glomerulonephritis 141 Yes No No No
N048 Nephrotic syndrome with other morphologic changes 141 Yes No No No
N049 Nephrotic syndrome with unspecified morphologic changes 141 Yes No No No
N04A Nephrotic syndrome with C3 glomerulonephritis 141 Yes No No No
N050 Unspecified nephritic syndrome with minor glomerular abnormality 141 Yes No No No
N051 Unspecified nephritic syndrome with focal and segmental glomerular lesions 141 Yes No No No
N052 Unspecified nephritic syndrome with diffuse membranous glomerulonephritis 141 Yes No No No
N053 Unspecified nephritic syndrome with diffuse mesangial proliferative glomerulonephritis 141 Yes No No No
N054 Unspecified nephritic syndrome with diffuse endocapillary proliferative glomerulonephritis 141 Yes No No No
N055 Unspecified nephritic syndrome with diffuse mesangiocapillary glomerulonephritis 141 Yes No No No
N056 Unspecified nephritic syndrome with dense deposit disease 141 Yes No No No
N057 Unspecified nephritic syndrome with diffuse crescentic glomerulonephritis 141 Yes No No No
N058 Unspecified nephritic syndrome with other morphologic changes 141 Yes No No No
N059 Unspecified nephritic syndrome with unspecified morphologic changes 141 Yes No No No
N05A Unspecified nephritic syndrome with C3 glomerulonephritis 141 Yes No No No
N060 Isolated proteinuria with minor glomerular abnormality 141 Yes No No No
N061 Isolated proteinuria with focal and segmental glomerular lesions 141 Yes No No No
N062 Isolated proteinuria with diffuse membranous glomerulonephritis 141 Yes No No No
N063 Isolated proteinuria with diffuse mesangial proliferative glomerulonephritis 141 Yes No No No
N064 Isolated proteinuria with diffuse endocapillary proliferative glomerulonephritis 141 Yes No No No
N065 Isolated proteinuria with diffuse mesangiocapillary glomerulonephritis 141 Yes No No No
N066 Isolated proteinuria with dense deposit disease 141 Yes No No No
N067 Isolated proteinuria with diffuse crescentic glomerulonephritis 141 Yes No No No
N068 Isolated proteinuria with other morphologic lesion 141 Yes No No No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 157 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

N069 Isolated proteinuria with unspecified morphologic lesion 141 Yes No No No


N06A Isolated proteinuria with C3 glomerulonephritis 141 Yes No No No
N070 Hereditary nephropathy, not elsewhere classified with minor glomerular abnormality 141 Yes No No No
N071 Hereditary nephropathy, not elsewhere classified with focal and segmental glomerular lesions 141 Yes No No No
N072 Hereditary nephropathy, not elsewhere classified with diffuse membranous glomerulonephritis 141 Yes No No No
N073 Hereditary nephropathy, not elsewhere classified with diffuse mesangial proliferative 141 Yes No No No
glomerulonephritis
N074 Hereditary nephropathy, not elsewhere classified with diffuse endocapillary proliferative 141 Yes No No No
glomerulonephritis
N075 Hereditary nephropathy, not elsewhere classified with diffuse mesangiocapillary glomerulonephritis 141 Yes No No No
N076 Hereditary nephropathy, not elsewhere classified with dense deposit disease 141 Yes No No No
N077 Hereditary nephropathy, not elsewhere classified with diffuse crescentic glomerulonephritis 141 Yes No No No
N078 Hereditary nephropathy, not elsewhere classified with other morphologic lesions 141 Yes No No No
N079 Hereditary nephropathy, not elsewhere classified with unspecified morphologic lesions 141 Yes No No No
N07A Hereditary nephropathy, not elsewhere classified with C3 glomerulonephritis 141 Yes No No No
N08 Glomerular disorders in diseases classified elsewhere 141 Yes No No No
N140 Analgesic nephropathy 141 Yes No No No
N141 Nephropathy induced by other drugs, medicaments and biological substances 141 Yes No No No
N142 Nephropathy induced by unspecified drug, medicament or biological substance 141 Yes No No No
N143 Nephropathy induced by heavy metals 141 Yes No No No
N144 Toxic nephropathy, not elsewhere classified 141 Yes No No No
N150 Balkan nephropathy 141 Yes No No No
N158 Other specified renal tubulo-interstitial diseases 141 Yes No No No
N170 Acute kidney failure with tubular necrosis 135 135 135 Yes Yes Yes No
N171 Acute kidney failure with acute cortical necrosis 135 135 135 Yes Yes Yes No
N172 Acute kidney failure with medullary necrosis 135 135 135 Yes Yes Yes No
N178 Other acute kidney failure 135 135 135 Yes Yes Yes No
N179 Acute kidney failure, unspecified 135 135 135 Yes Yes Yes No
N181 Chronic kidney disease, stage 1 139 Yes No No No
N182 Chronic kidney disease, stage 2 (mild) 139 Yes No No No
N183 Chronic kidney disease, stage 3 (moderate) 138 138 Yes No Yes No
N1830 Chronic kidney disease, stage 3 unspecified 138 138 Yes No Yes No
N1831 Chronic kidney disease, stage 3a 138 138 Yes No Yes No
N1832 Chronic kidney disease, stage 3b 138 138 Yes No Yes No
N184 Chronic kidney disease, stage 4 (severe) 137 137 137 263 Yes Yes Yes Yes
N185 Chronic kidney disease, stage 5 136 136 136 262 Yes Yes Yes Yes
N186 End stage renal disease 136 136 136 261 Yes Yes Yes Yes
N189 Chronic kidney disease, unspecified 139 Yes No No No
N19 Unspecified kidney failure 140 Yes No No No
N250 Renal osteodystrophy 87 No No No Yes
N251 Nephrogenic diabetes insipidus 23 23 23 41 Yes Yes Yes Yes
N2581 Secondary hyperparathyroidism of renal origin 23 23 23 41 Yes Yes Yes Yes
N262 Page kidney 187 No No No Yes
N280 Ischemia and infarction of kidney 107 107 107 Yes Yes Yes No
N99510 Cystostomy hemorrhage 176 176 176 Yes Yes Yes No
N99511 Cystostomy infection 176 176 176 Yes Yes Yes No
N99512 Cystostomy malfunction 176 176 176 Yes Yes Yes No
N99518 Other cystostomy complication 176 176 176 Yes Yes Yes No
N99520 Hemorrhage of incontinent external stoma of urinary tract 176 176 176 Yes Yes Yes No
N99521 Infection of incontinent external stoma of urinary tract 176 176 176 Yes Yes Yes No
N99522 Malfunction of incontinent external stoma of urinary tract 176 176 176 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 158 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

N99523 Herniation of incontinent stoma of urinary tract 176 176 176 Yes Yes Yes No
N99524 Stenosis of incontinent stoma of urinary tract 176 176 176 Yes Yes Yes No
N99528 Other complication of incontinent external stoma of urinary tract 176 176 176 Yes Yes Yes No
N99530 Hemorrhage of continent stoma of urinary tract 176 176 176 Yes Yes Yes No
N99531 Infection of continent stoma of urinary tract 176 176 176 Yes Yes Yes No
N99532 Malfunction of continent stoma of urinary tract 176 176 176 Yes Yes Yes No
N99533 Herniation of continent stoma of urinary tract 176 176 176 Yes Yes Yes No
N99534 Stenosis of continent stoma of urinary tract 176 176 176 Yes Yes Yes No
N99538 Other complication of continent stoma of urinary tract 176 176 176 Yes Yes Yes No
P0270 Newborn affected by fetal inflammatory response syndrome 2 2 2 Yes Yes Yes No
P360 Sepsis of newborn due to streptococcus, group B 2 2 2 Yes Yes Yes No
P3610 Sepsis of newborn due to unspecified streptococci 2 2 2 Yes Yes Yes No
P3619 Sepsis of newborn due to other streptococci 2 2 2 Yes Yes Yes No
P362 Sepsis of newborn due to Staphylococcus aureus 2 2 2 Yes Yes Yes No
P3630 Sepsis of newborn due to unspecified staphylococci 2 2 2 Yes Yes Yes No
P3639 Sepsis of newborn due to other staphylococci 2 2 2 Yes Yes Yes No
P364 Sepsis of newborn due to Escherichia coli 2 2 2 Yes Yes Yes No
P365 Sepsis of newborn due to anaerobes 2 2 2 Yes Yes Yes No
P368 Other bacterial sepsis of newborn 2 2 2 Yes Yes Yes No
P369 Bacterial sepsis of newborn, unspecified 2 2 2 Yes Yes Yes No
P91821 Neonatal cerebral infarction, right side of brain 100 100 100 206 Yes Yes Yes Yes
P91822 Neonatal cerebral infarction, left side of brain 100 100 100 206 Yes Yes Yes Yes
P91823 Neonatal cerebral infarction, bilateral 100 100 100 206 Yes Yes Yes Yes
P91829 Neonatal cerebral infarction, unspecified side 100 100 100 206 Yes Yes Yes Yes
Q000 Anencephaly 72 72 72 157 Yes Yes Yes Yes
Q001 Craniorachischisis 72 72 72 157 Yes Yes Yes Yes
Q002 Iniencephaly 72 72 72 157 Yes Yes Yes Yes
Q010 Frontal encephalocele 72 72 72 157 Yes Yes Yes Yes
Q011 Nasofrontal encephalocele 72 72 72 157 Yes Yes Yes Yes
Q012 Occipital encephalocele 72 72 72 157 Yes Yes Yes Yes
Q018 Encephalocele of other sites 72 72 72 157 Yes Yes Yes Yes
Q019 Encephalocele, unspecified 72 72 72 157 Yes Yes Yes Yes
Q02 Microcephaly 72 72 72 157 Yes Yes Yes Yes
Q030 Malformations of aqueduct of Sylvius 72 72 72 157 Yes Yes Yes Yes
Q031 Atresia of foramina of Magendie and Luschka 72 72 72 157 Yes Yes Yes Yes
Q038 Other congenital hydrocephalus 72 72 72 157 Yes Yes Yes Yes
Q039 Congenital hydrocephalus, unspecified 72 72 72 157 Yes Yes Yes Yes
Q040 Congenital malformations of corpus callosum 72 72 72 157 Yes Yes Yes Yes
Q041 Arhinencephaly 72 72 72 157 Yes Yes Yes Yes
Q042 Holoprosencephaly 72 72 72 157 Yes Yes Yes Yes
Q043 Other reduction deformities of brain 72 72 72 157 Yes Yes Yes Yes
Q044 Septo-optic dysplasia of brain 72 72 72 157 Yes Yes Yes Yes
Q045 Megalencephaly 72 72 72 157 Yes Yes Yes Yes
Q046 Congenital cerebral cysts 72 72 72 157 Yes Yes Yes Yes
Q048 Other specified congenital malformations of brain 72 72 72 157 Yes Yes Yes Yes
Q049 Congenital malformation of brain, unspecified 72 72 72 157 Yes Yes Yes Yes
Q050 Cervical spina bifida with hydrocephalus 72 72 72 157 Yes Yes Yes Yes
Q051 Thoracic spina bifida with hydrocephalus 72 72 72 157 Yes Yes Yes Yes
Q052 Lumbar spina bifida with hydrocephalus 72 72 72 157 Yes Yes Yes Yes
Q053 Sacral spina bifida with hydrocephalus 72 72 72 157 Yes Yes Yes Yes
Q054 Unspecified spina bifida with hydrocephalus 72 72 72 157 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 159 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

Q055 Cervical spina bifida without hydrocephalus 72 72 72 157 Yes Yes Yes Yes
Q056 Thoracic spina bifida without hydrocephalus 72 72 72 157 Yes Yes Yes Yes
Q057 Lumbar spina bifida without hydrocephalus 72 72 72 157 Yes Yes Yes Yes
Q058 Sacral spina bifida without hydrocephalus 72 72 72 157 Yes Yes Yes Yes
Q059 Spina bifida, unspecified 72 72 72 157 Yes Yes Yes Yes
Q060 Amyelia 72 72 72 157 Yes Yes Yes Yes
Q061 Hypoplasia and dysplasia of spinal cord 72 72 72 157 Yes Yes Yes Yes
Q062 Diastematomyelia 72 72 72 157 Yes Yes Yes Yes
Q063 Other congenital cauda equina malformations 72 72 72 157 Yes Yes Yes Yes
Q064 Hydromyelia 72 72 72 157 Yes Yes Yes Yes
Q068 Other specified congenital malformations of spinal cord 72 72 72 157 Yes Yes Yes Yes
Q069 Congenital malformation of spinal cord, unspecified 72 72 72 157 Yes Yes Yes Yes
Q0700 Arnold-Chiari syndrome without spina bifida or hydrocephalus 72 72 72 157 Yes Yes Yes Yes
Q0701 Arnold-Chiari syndrome with spina bifida 72 72 72 157 Yes Yes Yes Yes
Q0702 Arnold-Chiari syndrome with hydrocephalus 72 72 72 157 Yes Yes Yes Yes
Q0703 Arnold-Chiari syndrome with spina bifida and hydrocephalus 72 72 72 157 Yes Yes Yes Yes
Q078 Other specified congenital malformations of nervous system 72 72 72 157 Yes Yes Yes Yes
Q079 Congenital malformation of nervous system, unspecified 72 72 72 157 Yes Yes Yes Yes
Q245 Malformation of coronary vessels 188 No No No Yes
Q6111 Cystic dilatation of collecting ducts 139 Yes No No No
Q6119 Other polycystic kidney, infantile type 139 Yes No No No
Q7960 Ehlers-Danlos syndrome, unspecified 84 No No No Yes
Q7961 Classical Ehlers-Danlos syndrome 84 No No No Yes
Q7962 Hypermobile Ehlers-Danlos syndrome 84 No No No Yes
Q7963 Vascular Ehlers-Danlos syndrome 84 No No No Yes
Q7969 Other Ehlers-Danlos syndromes 84 No No No Yes
Q8500 Neurofibromatosis, unspecified 12 12 12 Yes Yes Yes No
Q8501 Neurofibromatosis, type 1 12 12 12 Yes Yes Yes No
Q8502 Neurofibromatosis, type 2 12 12 12 Yes Yes Yes No
Q8503 Schwannomatosis 12 12 12 Yes Yes Yes No
Q8509 Other neurofibromatosis 12 12 12 Yes Yes Yes No
Q851 Tuberous sclerosis 12 12 12 19 Yes Yes Yes Yes
Q858 Other phakomatoses, not elsewhere classified 12 12 12 19 Yes Yes Yes Yes
Q859 Phakomatosis, unspecified 12 12 12 19 Yes Yes Yes Yes
Q8711 Prader-Willi syndrome 148 No No No Yes
Q8740 Marfan's syndrome, unspecified 84 No No No Yes
Q87410 Marfan's syndrome with aortic dilation 84 No No No Yes
Q87418 Marfan's syndrome with other cardiovascular manifestations 84 No No No Yes
Q8742 Marfan's syndrome with ocular manifestations 84 No No No Yes
Q8743 Marfan's syndrome with skeletal manifestation 84 No No No Yes
Q8782 Arterial tortuosity syndrome 84 No No No Yes
Q910 Trisomy 18, nonmosaicism (meiotic nondisjunction) 148 No No No Yes
Q911 Trisomy 18, mosaicism (mitotic nondisjunction) 148 No No No Yes
Q912 Trisomy 18, translocation 148 No No No Yes
Q913 Trisomy 18, unspecified 148 No No No Yes
Q914 Trisomy 13, nonmosaicism (meiotic nondisjunction) 148 No No No Yes
Q915 Trisomy 13, mosaicism (mitotic nondisjunction) 148 No No No Yes
Q916 Trisomy 13, translocation 148 No No No Yes
Q917 Trisomy 13, unspecified 148 No No No Yes
Q920 Whole chromosome trisomy, nonmosaicism (meiotic nondisjunction) 148 No No No Yes
Q921 Whole chromosome trisomy, mosaicism (mitotic nondisjunction) 148 No No No Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 160 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

Q922 Partial trisomy 148 No No No Yes


Q925 Duplications with other complex rearrangements 148 No No No Yes
Q9261 Marker chromosomes in normal individual 148 No No No Yes
Q9262 Marker chromosomes in abnormal individual 148 No No No Yes
Q927 Triploidy and polyploidy 148 No No No Yes
Q928 Other specified trisomies and partial trisomies of autosomes 148 No No No Yes
Q929 Trisomy and partial trisomy of autosomes, unspecified 148 No No No Yes
Q930 Whole chromosome monosomy, nonmosaicism (meiotic nondisjunction) 148 No No No Yes
Q931 Whole chromosome monosomy, mosaicism (mitotic nondisjunction) 148 No No No Yes
Q932 Chromosome replaced with ring, dicentric or isochromosome 148 No No No Yes
Q933 Deletion of short arm of chromosome 4 148 No No No Yes
Q934 Deletion of short arm of chromosome 5 148 No No No Yes
Q9351 Angelman syndrome 148 No No No Yes
Q9359 Other deletions of part of a chromosome 148 No No No Yes
Q937 Deletions with other complex rearrangements 148 No No No Yes
Q9381 Velo-cardio-facial syndrome 148 No No No Yes
Q9382 Williams syndrome 148 No No No Yes
Q9388 Other microdeletions 148 No No No Yes
Q9389 Other deletions from the autosomes 148 No No No Yes
Q939 Deletion from autosomes, unspecified 148 No No No Yes
Q952 Balanced autosomal rearrangement in abnormal individual 148 No No No Yes
Q953 Balanced sex/autosomal rearrangement in abnormal individual 148 No No No Yes
Q992 Fragile X chromosome 148 No No No Yes
R092 Respiratory arrest 83 83 83 Yes Yes Yes No
R4020 Unspecified coma 80 80 80 Yes Yes Yes No
R402110 Coma scale, eyes open, never, unspecified time 80 80 80 Yes Yes Yes No
R402111 Coma scale, eyes open, never, in the field [EMT or ambulance] 80 80 80 Yes Yes Yes No
R402112 Coma scale, eyes open, never, at arrival to emergency department 80 80 80 Yes Yes Yes No
R402113 Coma scale, eyes open, never, at hospital admission 80 80 80 Yes Yes Yes No
R402114 Coma scale, eyes open, never, 24 hours or more after hospital admission 80 80 80 Yes Yes Yes No
R402120 Coma scale, eyes open, to pain, unspecified time 80 80 80 Yes Yes Yes No
R402121 Coma scale, eyes open, to pain, in the field [EMT or ambulance] 80 80 80 Yes Yes Yes No
R402122 Coma scale, eyes open, to pain, at arrival to emergency department 80 80 80 Yes Yes Yes No
R402123 Coma scale, eyes open, to pain, at hospital admission 80 80 80 Yes Yes Yes No
R402124 Coma scale, eyes open, to pain, 24 hours or more after hospital admission 80 80 80 Yes Yes Yes No
R402210 Coma scale, best verbal response, none, unspecified time 80 80 80 Yes Yes Yes No
R402211 Coma scale, best verbal response, none, in the field [EMT or ambulance] 80 80 80 Yes Yes Yes No
R402212 Coma scale, best verbal response, none, at arrival to emergency department 80 80 80 Yes Yes Yes No
R402213 Coma scale, best verbal response, none, at hospital admission 80 80 80 Yes Yes Yes No
R402214 Coma scale, best verbal response, none, 24 hours or more after hospital admission 80 80 80 Yes Yes Yes No
R402220 Coma scale, best verbal response, incomprehensible words, unspecified time 80 80 80 Yes Yes Yes No
R402221 Coma scale, best verbal response, incomprehensible words, in the field [EMT or ambulance] 80 80 80 Yes Yes Yes No
R402222 Coma scale, best verbal response, incomprehensible words, at arrival to emergency department 80 80 80 Yes Yes Yes No
R402223 Coma scale, best verbal response, incomprehensible words, at hospital admission 80 80 80 Yes Yes Yes No
R402224 Coma scale, best verbal response, incomprehensible words, 24 hours or more after hospital 80 80 80 Yes Yes Yes No
admission
R402310 Coma scale, best motor response, none, unspecified time 80 80 80 Yes Yes Yes No
R402311 Coma scale, best motor response, none, in the field [EMT or ambulance] 80 80 80 Yes Yes Yes No
R402312 Coma scale, best motor response, none, at arrival to emergency department 80 80 80 Yes Yes Yes No
R402313 Coma scale, best motor response, none, at hospital admission 80 80 80 Yes Yes Yes No
R402314 Coma scale, best motor response, none, 24 hours or more after hospital admission 80 80 80 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 161 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

R402320 Coma scale, best motor response, extension, unspecified time 80 80 80 Yes Yes Yes No
R402321 Coma scale, best motor response, extension, in the field [EMT or ambulance] 80 80 80 Yes Yes Yes No
R402322 Coma scale, best motor response, extension, at arrival to emergency department 80 80 80 Yes Yes Yes No
R402323 Coma scale, best motor response, extension, at hospital admission 80 80 80 Yes Yes Yes No
R402324 Coma scale, best motor response, extension, 24 hours or more after hospital admission 80 80 80 Yes Yes Yes No
R402340 Coma scale, best motor response, flexion withdrawal, unspecified time 80 80 80 Yes Yes Yes No
R402341 Coma scale, best motor response, flexion withdrawal, in the field [EMT or ambulance] 80 80 80 Yes Yes Yes No
R402342 Coma scale, best motor response, flexion withdrawal, at arrival to emergency department 80 80 80 Yes Yes Yes No
R402343 Coma scale, best motor response, flexion withdrawal, at hospital admission 80 80 80 Yes Yes Yes No
R402344 Coma scale, best motor response, flexion withdrawal, 24 hours or more after hospital admission 80 80 80 Yes Yes Yes No
R402430 Glasgow coma scale score 3-8, unspecified time 80 80 80 Yes Yes Yes No
R402431 Glasgow coma scale score 3-8, in the field [EMT or ambulance] 80 80 80 Yes Yes Yes No
R402432 Glasgow coma scale score 3-8, at arrival to emergency department 80 80 80 Yes Yes Yes No
R402433 Glasgow coma scale score 3-8, at hospital admission 80 80 80 Yes Yes Yes No
R402434 Glasgow coma scale score 3-8, 24 hours or more after hospital admission 80 80 80 Yes Yes Yes No
R402440 Other coma, without documented Glasgow coma scale score, or with partial score reported, 80 80 80 Yes Yes Yes No
unspecified time
R402441 Other coma, without documented Glasgow coma scale score, or with partial score reported, in the 80 80 80 Yes Yes Yes No
field [EMT or ambulance]
R402442 Other coma, without documented Glasgow coma scale score, or with partial score reported, at 80 80 80 Yes Yes Yes No
arrival to emergency department
R402443 Other coma, without documented Glasgow coma scale score, or with partial score reported, at 80 80 80 Yes Yes Yes No
hospital admission
R402444 Other coma, without documented Glasgow coma scale score, or with partial score reported, 24 80 80 80 Yes Yes Yes No
hours or more after hospital admission
R403 Persistent vegetative state 80 80 80 Yes Yes Yes No
R532 Functional quadriplegia 70 70 70 Yes Yes Yes No
R5600 Simple febrile convulsions 79 79 79 165 Yes Yes Yes Yes
R5601 Complex febrile convulsions 79 79 79 165 Yes Yes Yes Yes
R561 Post traumatic seizures 79 79 79 165 Yes Yes Yes Yes
R569 Unspecified convulsions 79 79 79 165 Yes Yes Yes Yes
R570 Cardiogenic shock 84 84 84 Yes Yes Yes No
R571 Hypovolemic shock 2 2 2 Yes Yes Yes No
R578 Other shock 2 2 2 Yes Yes Yes No
R579 Shock, unspecified 84 84 84 Yes Yes Yes No
R64 Cachexia 21 21 21 Yes Yes Yes No
R6510 Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ 2 2 2 Yes Yes Yes No
dysfunction
R6511 Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ 2 2 2 Yes Yes Yes No
dysfunction
R6520 Severe sepsis without septic shock 2 2 2 Yes Yes Yes No
R6521 Severe sepsis with septic shock 2 2 2 Yes Yes Yes No
S020XXA Fracture of vault of skull, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S020XXB Fracture of vault of skull, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S020XXS Fracture of vault of skull, sequela 167 167 167 Yes Yes Yes No
S02101A Fracture of base of skull, right side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02101B Fracture of base of skull, right side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02101S Fracture of base of skull, right side, sequela 167 167 167 Yes Yes Yes No
S02102A Fracture of base of skull, left side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02102B Fracture of base of skull, left side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02102S Fracture of base of skull, left side, sequela 167 167 167 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 162 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S02109A Fracture of base of skull, unspecified side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02109B Fracture of base of skull, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02109S Fracture of base of skull, unspecified side, sequela 167 167 167 Yes Yes Yes No
S02110A Type I occipital condyle fracture, unspecified side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02110B Type I occipital condyle fracture, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02110S Type I occipital condyle fracture, unspecified side, sequela 167 167 167 Yes Yes Yes No
S02111A Type II occipital condyle fracture, unspecified side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02111B Type II occipital condyle fracture, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02111S Type II occipital condyle fracture, unspecified side, sequela 167 167 167 Yes Yes Yes No
S02112A Type III occipital condyle fracture, unspecified side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02112B Type III occipital condyle fracture, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02112S Type III occipital condyle fracture, unspecified side, sequela 167 167 167 Yes Yes Yes No
S02113A Unspecified occipital condyle fracture, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02113B Unspecified occipital condyle fracture, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02113S Unspecified occipital condyle fracture, sequela 167 167 167 Yes Yes Yes No
S02118A Other fracture of occiput, unspecified side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02118B Other fracture of occiput, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02118S Other fracture of occiput, unspecified side, sequela 167 167 167 Yes Yes Yes No
S02119A Unspecified fracture of occiput, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02119B Unspecified fracture of occiput, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02119S Unspecified fracture of occiput, sequela 167 167 167 Yes Yes Yes No
S0211AA Type I occipital condyle fracture, right side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0211AB Type I occipital condyle fracture, right side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0211AS Type I occipital condyle fracture, right side, sequela 167 167 167 Yes Yes Yes No
S0211BA Type I occipital condyle fracture, left side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0211BB Type I occipital condyle fracture, left side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0211BS Type I occipital condyle fracture, left side, sequela 167 167 167 Yes Yes Yes No
S0211CA Type II occipital condyle fracture, right side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0211CB Type II occipital condyle fracture, right side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0211CS Type II occipital condyle fracture, right side, sequela 167 167 167 Yes Yes Yes No
S0211DA Type II occipital condyle fracture, left side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0211DB Type II occipital condyle fracture, left side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0211DS Type II occipital condyle fracture, left side, sequela 167 167 167 Yes Yes Yes No
S0211EA Type III occipital condyle fracture, right side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0211EB Type III occipital condyle fracture, right side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0211ES Type III occipital condyle fracture, right side, sequela 167 167 167 Yes Yes Yes No
S0211FA Type III occipital condyle fracture, left side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0211FB Type III occipital condyle fracture, left side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0211FS Type III occipital condyle fracture, left side, sequela 167 167 167 Yes Yes Yes No
S0211GA Other fracture of occiput, right side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0211GB Other fracture of occiput, right side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0211GS Other fracture of occiput, right side, sequela 167 167 167 Yes Yes Yes No
S0211HA Other fracture of occiput, left side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0211HB Other fracture of occiput, left side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0211HS Other fracture of occiput, left side, sequela 167 167 167 Yes Yes Yes No
S02121A Fracture of orbital roof, right side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02121B Fracture of orbital roof, right side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02121S Fracture of orbital roof, right side, sequela 167 167 167 Yes Yes Yes No
S02122A Fracture of orbital roof, left side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02122B Fracture of orbital roof, left side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02122S Fracture of orbital roof, left side, sequela 167 167 167 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 163 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S02129A Fracture of orbital roof, unspecified side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02129B Fracture of orbital roof, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02129S Fracture of orbital roof, unspecified side, sequela 167 167 167 Yes Yes Yes No
S0219XA Other fracture of base of skull, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0219XB Other fracture of base of skull, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0219XS Other fracture of base of skull, sequela 167 167 167 Yes Yes Yes No
S0230XA Fracture of orbital floor, unspecified side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0230XB Fracture of orbital floor, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0230XS Fracture of orbital floor, unspecified side, sequela 167 167 167 Yes Yes Yes No
S0231XA Fracture of orbital floor, right side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0231XB Fracture of orbital floor, right side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0231XS Fracture of orbital floor, right side, sequela 167 167 167 Yes Yes Yes No
S0232XA Fracture of orbital floor, left side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0232XB Fracture of orbital floor, left side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0232XS Fracture of orbital floor, left side, sequela 167 167 167 Yes Yes Yes No
S02400A Malar fracture, unspecified side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02400B Malar fracture, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02400S Malar fracture, unspecified side, sequela 167 167 167 Yes Yes Yes No
S02401A Maxillary fracture, unspecified side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02401B Maxillary fracture, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02401S Maxillary fracture, unspecified side, sequela 167 167 167 Yes Yes Yes No
S02402A Zygomatic fracture, unspecified side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02402B Zygomatic fracture, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02402S Zygomatic fracture, unspecified side, sequela 167 167 167 Yes Yes Yes No
S0240AA Malar fracture, right side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0240AB Malar fracture, right side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0240AS Malar fracture, right side, sequela 167 167 167 Yes Yes Yes No
S0240BA Malar fracture, left side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0240BB Malar fracture, left side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0240BS Malar fracture, left side, sequela 167 167 167 Yes Yes Yes No
S0240CA Maxillary fracture, right side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0240CB Maxillary fracture, right side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0240CS Maxillary fracture, right side, sequela 167 167 167 Yes Yes Yes No
S0240DA Maxillary fracture, left side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0240DB Maxillary fracture, left side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0240DS Maxillary fracture, left side, sequela 167 167 167 Yes Yes Yes No
S0240EA Zygomatic fracture, right side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0240EB Zygomatic fracture, right side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0240ES Zygomatic fracture, right side, sequela 167 167 167 Yes Yes Yes No
S0240FA Zygomatic fracture, left side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0240FB Zygomatic fracture, left side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0240FS Zygomatic fracture, left side, sequela 167 167 167 Yes Yes Yes No
S02411A LeFort I fracture, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02411B LeFort I fracture, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02411S LeFort I fracture, sequela 167 167 167 Yes Yes Yes No
S02412A LeFort II fracture, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02412B LeFort II fracture, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02412S LeFort II fracture, sequela 167 167 167 Yes Yes Yes No
S02413A LeFort III fracture, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02413B LeFort III fracture, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02413S LeFort III fracture, sequela 167 167 167 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 164 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S0242XA Fracture of alveolus of maxilla, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0242XB Fracture of alveolus of maxilla, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0242XS Fracture of alveolus of maxilla, sequela 167 167 167 Yes Yes Yes No
S02600A Fracture of unspecified part of body of mandible, unspecified side, initial encounter for closed 167 167 167 Yes Yes Yes No
fracture
S02600B Fracture of unspecified part of body of mandible, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No

S02600S Fracture of unspecified part of body of mandible, unspecified side, sequela 167 167 167 Yes Yes Yes No
S02601A Fracture of unspecified part of body of right mandible, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02601B Fracture of unspecified part of body of right mandible, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02601S Fracture of unspecified part of body of right mandible, sequela 167 167 167 Yes Yes Yes No
S02602A Fracture of unspecified part of body of left mandible, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02602B Fracture of unspecified part of body of left mandible, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02602S Fracture of unspecified part of body of left mandible, sequela 167 167 167 Yes Yes Yes No
S02609A Fracture of mandible, unspecified, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02609B Fracture of mandible, unspecified, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02609S Fracture of mandible, unspecified, sequela 167 167 167 Yes Yes Yes No
S02610A Fracture of condylar process of mandible, unspecified side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02610B Fracture of condylar process of mandible, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02610S Fracture of condylar process of mandible, unspecified side, sequela 167 167 167 Yes Yes Yes No
S02611A Fracture of condylar process of right mandible, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02611B Fracture of condylar process of right mandible, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02611S Fracture of condylar process of right mandible, sequela 167 167 167 Yes Yes Yes No
S02612A Fracture of condylar process of left mandible, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02612B Fracture of condylar process of left mandible, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02612S Fracture of condylar process of left mandible, sequela 167 167 167 Yes Yes Yes No
S02620A Fracture of subcondylar process of mandible, unspecified side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02620B Fracture of subcondylar process of mandible, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02620S Fracture of subcondylar process of mandible, unspecified side, sequela 167 167 167 Yes Yes Yes No
S02621A Fracture of subcondylar process of right mandible, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02621B Fracture of subcondylar process of right mandible, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02621S Fracture of subcondylar process of right mandible, sequela 167 167 167 Yes Yes Yes No
S02622A Fracture of subcondylar process of left mandible, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02622B Fracture of subcondylar process of left mandible, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02622S Fracture of subcondylar process of left mandible, sequela 167 167 167 Yes Yes Yes No
S02630A Fracture of coronoid process of mandible, unspecified side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02630B Fracture of coronoid process of mandible, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02630S Fracture of coronoid process of mandible, unspecified side, sequela 167 167 167 Yes Yes Yes No
S02631A Fracture of coronoid process of right mandible, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02631B Fracture of coronoid process of right mandible, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02631S Fracture of coronoid process of right mandible, sequela 167 167 167 Yes Yes Yes No
S02632A Fracture of coronoid process of left mandible, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02632B Fracture of coronoid process of left mandible, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02632S Fracture of coronoid process of left mandible, sequela 167 167 167 Yes Yes Yes No
S02640A Fracture of ramus of mandible, unspecified side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02640B Fracture of ramus of mandible, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02640S Fracture of ramus of mandible, unspecified side, sequela 167 167 167 Yes Yes Yes No
S02641A Fracture of ramus of right mandible, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02641B Fracture of ramus of right mandible, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02641S Fracture of ramus of right mandible, sequela 167 167 167 Yes Yes Yes No
S02642A Fracture of ramus of left mandible, initial encounter for closed fracture 167 167 167 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 165 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S02642B Fracture of ramus of left mandible, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02642S Fracture of ramus of left mandible, sequela 167 167 167 Yes Yes Yes No
S02650A Fracture of angle of mandible, unspecified side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02650B Fracture of angle of mandible, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02650S Fracture of angle of mandible, unspecified side, sequela 167 167 167 Yes Yes Yes No
S02651A Fracture of angle of right mandible, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02651B Fracture of angle of right mandible, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02651S Fracture of angle of right mandible, sequela 167 167 167 Yes Yes Yes No
S02652A Fracture of angle of left mandible, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02652B Fracture of angle of left mandible, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02652S Fracture of angle of left mandible, sequela 167 167 167 Yes Yes Yes No
S0266XA Fracture of symphysis of mandible, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0266XB Fracture of symphysis of mandible, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0266XS Fracture of symphysis of mandible, sequela 167 167 167 Yes Yes Yes No
S02670A Fracture of alveolus of mandible, unspecified side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02670B Fracture of alveolus of mandible, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02670S Fracture of alveolus of mandible, unspecified side, sequela 167 167 167 Yes Yes Yes No
S02671A Fracture of alveolus of right mandible, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02671B Fracture of alveolus of right mandible, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02671S Fracture of alveolus of right mandible, sequela 167 167 167 Yes Yes Yes No
S02672A Fracture of alveolus of left mandible, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02672B Fracture of alveolus of left mandible, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02672S Fracture of alveolus of left mandible, sequela 167 167 167 Yes Yes Yes No
S0269XA Fracture of mandible of other specified site, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0269XB Fracture of mandible of other specified site, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0269XS Fracture of mandible of other specified site, sequela 167 167 167 Yes Yes Yes No
S0280XA Fracture of other specified skull and facial bones, unspecified side, initial encounter for closed 167 167 167 Yes Yes Yes No
fracture
S0280XB Fracture of other specified skull and facial bones, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0280XS Fracture of other specified skull and facial bones, unspecified side, sequela 167 167 167 Yes Yes Yes No
S0281XA Fracture of other specified skull and facial bones, right side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0281XB Fracture of other specified skull and facial bones, right side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0281XS Fracture of other specified skull and facial bones, right side, sequela 167 167 167 Yes Yes Yes No
S0282XA Fracture of other specified skull and facial bones, left side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0282XB Fracture of other specified skull and facial bones, left side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0282XS Fracture of other specified skull and facial bones, left side, sequela 167 167 167 Yes Yes Yes No
S02831A Fracture of medial orbital wall, right side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02831B Fracture of medial orbital wall, right side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02831S Fracture of medial orbital wall, right side, sequela 167 167 167 Yes Yes Yes No
S02832A Fracture of medial orbital wall, left side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02832B Fracture of medial orbital wall, left side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02832S Fracture of medial orbital wall, left side, sequela 167 167 167 Yes Yes Yes No
S02839A Fracture of medial orbital wall, unspecified side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02839B Fracture of medial orbital wall, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02839S Fracture of medial orbital wall, unspecified side, sequela 167 167 167 Yes Yes Yes No
S02841A Fracture of lateral orbital wall, right side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02841B Fracture of lateral orbital wall, right side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02841S Fracture of lateral orbital wall, right side, sequela 167 167 167 Yes Yes Yes No
S02842A Fracture of lateral orbital wall, left side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02842B Fracture of lateral orbital wall, left side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02842S Fracture of lateral orbital wall, left side, sequela 167 167 167 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 166 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S02849A Fracture of lateral orbital wall, unspecified side, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S02849B Fracture of lateral orbital wall, unspecified side, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S02849S Fracture of lateral orbital wall, unspecified side, sequela 167 167 167 Yes Yes Yes No
S0285XA Fracture of orbit, unspecified, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0285XB Fracture of orbit, unspecified, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0285XS Fracture of orbit, unspecified, sequela 167 167 167 Yes Yes Yes No
S0291XA Unspecified fracture of skull, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0291XB Unspecified fracture of skull, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0291XS Unspecified fracture of skull, sequela 167 167 167 Yes Yes Yes No
S0292XA Unspecified fracture of facial bones, initial encounter for closed fracture 167 167 167 Yes Yes Yes No
S0292XB Unspecified fracture of facial bones, initial encounter for open fracture 167 167 167 Yes Yes Yes No
S0292XS Unspecified fracture of facial bones, sequela 167 167 167 Yes Yes Yes No
S060X0S Concussion without loss of consciousness, sequela 167 167 167 Yes Yes Yes No
S060X1S Concussion with loss of consciousness of 30 minutes or less, sequela 167 167 167 Yes Yes Yes No
S060X9S Concussion with loss of consciousness of unspecified duration, sequela 167 167 167 Yes Yes Yes No
S061X0A Traumatic cerebral edema without loss of consciousness, initial encounter 167 167 167 Yes Yes Yes No
S061X0S Traumatic cerebral edema without loss of consciousness, sequela 167 167 167 Yes Yes Yes No
S061X1A Traumatic cerebral edema with loss of consciousness of 30 minutes or less, initial encounter 167 167 167 Yes Yes Yes No
S061X1S Traumatic cerebral edema with loss of consciousness of 30 minutes or less, sequela 167 167 167 Yes Yes Yes No
S061X2A Traumatic cerebral edema with loss of consciousness of 31 minutes to 59 minutes, initial encounter 167 167 167 Yes Yes Yes No
S061X2S Traumatic cerebral edema with loss of consciousness of 31 minutes to 59 minutes, sequela 167 167 167 Yes Yes Yes No
S061X3A Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes, initial 166 166 166 Yes Yes Yes No
encounter
S061X3S Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela 167 167 167 Yes Yes Yes No
S061X4A Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours, initial encounter 166 166 166 Yes Yes Yes No
S061X4S Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours, sequela 167 167 167 Yes Yes Yes No
S061X5A Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre- 166 166 166 Yes Yes Yes No
existing conscious level, initial encounter
S061X5S Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre- 167 167 167 Yes Yes Yes No
existing conscious level, sequela
S061X6A Traumatic cerebral edema with loss of consciousness greater than 24 hours without return to pre- 166 166 166 Yes Yes Yes No
existing conscious level with patient surviving, initial encounter
S061X6S Traumatic cerebral edema with loss of consciousness greater than 24 hours without return to pre- 167 167 167 Yes Yes Yes No
existing conscious level with patient surviving, sequela
S061X9A Traumatic cerebral edema with loss of consciousness of unspecified duration, initial encounter 167 167 167 Yes Yes Yes No
S061X9S Traumatic cerebral edema with loss of consciousness of unspecified duration, sequela 167 167 167 Yes Yes Yes No
S062X0A Diffuse traumatic brain injury without loss of consciousness, initial encounter 167 167 167 Yes Yes Yes No
S062X0S Diffuse traumatic brain injury without loss of consciousness, sequela 167 167 167 Yes Yes Yes No
S062X1A Diffuse traumatic brain injury with loss of consciousness of 30 minutes or less, initial encounter 167 167 167 Yes Yes Yes No
S062X1S Diffuse traumatic brain injury with loss of consciousness of 30 minutes or less, sequela 167 167 167 Yes Yes Yes No
S062X2A Diffuse traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes, initial 167 167 167 Yes Yes Yes No
encounter
S062X2S Diffuse traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes, sequela 167 167 167 Yes Yes Yes No
S062X3A Diffuse traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes, initial 166 166 166 Yes Yes Yes No
encounter
S062X3S Diffuse traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela 167 167 167 Yes Yes Yes No
S062X4A Diffuse traumatic brain injury with loss of consciousness of 6 hours to 24 hours, initial encounter 166 166 166 Yes Yes Yes No
S062X4S Diffuse traumatic brain injury with loss of consciousness of 6 hours to 24 hours, sequela 167 167 167 Yes Yes Yes No
S062X5A Diffuse traumatic brain injury with loss of consciousness greater than 24 hours with return to pre- 166 166 166 Yes Yes Yes No
existing conscious levels, initial encounter

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 167 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S062X5S Diffuse traumatic brain injury with loss of consciousness greater than 24 hours with return to pre- 167 167 167 Yes Yes Yes No
existing conscious levels, sequela
S062X6A Diffuse traumatic brain injury with loss of consciousness greater than 24 hours without return to pre- 166 166 166 Yes Yes Yes No
existing conscious level with patient surviving, initial encounter
S062X6S Diffuse traumatic brain injury with loss of consciousness greater than 24 hours without return to pre- 167 167 167 Yes Yes Yes No
existing conscious level with patient surviving, sequela
S062X9A Diffuse traumatic brain injury with loss of consciousness of unspecified duration, initial encounter 167 167 167 Yes Yes Yes No
S062X9S Diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela 167 167 167 Yes Yes Yes No
S06300A Unspecified focal traumatic brain injury without loss of consciousness, initial encounter 167 167 167 Yes Yes Yes No
S06300S Unspecified focal traumatic brain injury without loss of consciousness, sequela 167 167 167 Yes Yes Yes No
S06301A Unspecified focal traumatic brain injury with loss of consciousness of 30 minutes or less, initial 167 167 167 Yes Yes Yes No
encounter
S06301S Unspecified focal traumatic brain injury with loss of consciousness of 30 minutes or less, sequela 167 167 167 Yes Yes Yes No
S06302A Unspecified focal traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes, 167 167 167 Yes Yes Yes No
initial encounter
S06302S Unspecified focal traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes, 167 167 167 Yes Yes Yes No
sequela
S06303A Unspecified focal traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes, 166 166 166 Yes Yes Yes No
initial encounter
S06303S Unspecified focal traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes, 167 167 167 Yes Yes Yes No
sequela
S06304A Unspecified focal traumatic brain injury with loss of consciousness of 6 hours to 24 hours, initial 166 166 166 Yes Yes Yes No
encounter
S06304S Unspecified focal traumatic brain injury with loss of consciousness of 6 hours to 24 hours, sequela 167 167 167 Yes Yes Yes No
S06305A Unspecified focal traumatic brain injury with loss of consciousness greater than 24 hours with return 166 166 166 Yes Yes Yes No
to pre-existing conscious level, initial encounter
S06305S Unspecified focal traumatic brain injury with loss of consciousness greater than 24 hours with return 167 167 167 Yes Yes Yes No
to pre-existing conscious level, sequela
S06306A Unspecified focal traumatic brain injury with loss of consciousness greater than 24 hours without 166 166 166 Yes Yes Yes No
return to pre-existing conscious level with patient surviving, initial encounter
S06306S Unspecified focal traumatic brain injury with loss of consciousness greater than 24 hours without 167 167 167 Yes Yes Yes No
return to pre-existing conscious level with patient surviving, sequela
S06309A Unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, initial 167 167 167 Yes Yes Yes No
encounter
S06309S Unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, sequela 167 167 167 Yes Yes Yes No
S06310A Contusion and laceration of right cerebrum without loss of consciousness, initial encounter 167 167 167 Yes Yes Yes No
S06310S Contusion and laceration of right cerebrum without loss of consciousness, sequela 167 167 167 Yes Yes Yes No
S06311A Contusion and laceration of right cerebrum with loss of consciousness of 30 minutes or less, initial 167 167 167 Yes Yes Yes No
encounter
S06311S Contusion and laceration of right cerebrum with loss of consciousness of 30 minutes or less, sequela 167 167 167 Yes Yes Yes No
S06312A Contusion and laceration of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, 167 167 167 Yes Yes Yes No
initial encounter
S06312S Contusion and laceration of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, 167 167 167 Yes Yes Yes No
sequela
S06313A Contusion and laceration of right cerebrum with loss of consciousness of 1 hour to 5 hours 59 166 166 166 Yes Yes Yes No
minutes, initial encounter
S06313S Contusion and laceration of right cerebrum with loss of consciousness of 1 hour to 5 hours 59 167 167 167 Yes Yes Yes No
minutes, sequela
S06314A Contusion and laceration of right cerebrum with loss of consciousness of 6 hours to 24 hours, initial 166 166 166 Yes Yes Yes No
encounter

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 168 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S06314S Contusion and laceration of right cerebrum with loss of consciousness of 6 hours to 24 hours, 167 167 167 Yes Yes Yes No
sequela
S06315A Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours with 166 166 166 Yes Yes Yes No
return to pre-existing conscious level, initial encounter
S06315S Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours with 167 167 167 Yes Yes Yes No
return to pre-existing conscious level, sequela
S06316A Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours without 166 166 166 Yes Yes Yes No
return to pre-existing conscious level with patient surviving, initial encounter
S06316S Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours without 167 167 167 Yes Yes Yes No
return to pre-existing conscious level with patient surviving, sequela
S06319A Contusion and laceration of right cerebrum with loss of consciousness of unspecified duration, initial 167 167 167 Yes Yes Yes No
encounter
S06319S Contusion and laceration of right cerebrum with loss of consciousness of unspecified duration, 167 167 167 Yes Yes Yes No
sequela
S06320A Contusion and laceration of left cerebrum without loss of consciousness, initial encounter 167 167 167 Yes Yes Yes No
S06320S Contusion and laceration of left cerebrum without loss of consciousness, sequela 167 167 167 Yes Yes Yes No
S06321A Contusion and laceration of left cerebrum with loss of consciousness of 30 minutes or less, initial 167 167 167 Yes Yes Yes No
encounter
S06321S Contusion and laceration of left cerebrum with loss of consciousness of 30 minutes or less, sequela 167 167 167 Yes Yes Yes No
S06322A Contusion and laceration of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, 167 167 167 Yes Yes Yes No
initial encounter
S06322S Contusion and laceration of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, 167 167 167 Yes Yes Yes No
sequela
S06323A Contusion and laceration of left cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, 166 166 166 Yes Yes Yes No
initial encounter
S06323S Contusion and laceration of left cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, 167 167 167 Yes Yes Yes No
sequela
S06324A Contusion and laceration of left cerebrum with loss of consciousness of 6 hours to 24 hours, initial 166 166 166 Yes Yes Yes No
encounter
S06324S Contusion and laceration of left cerebrum with loss of consciousness of 6 hours to 24 hours, sequela 167 167 167 Yes Yes Yes No
S06325A Contusion and laceration of left cerebrum with loss of consciousness greater than 24 hours with 166 166 166 Yes Yes Yes No
return to pre-existing conscious level, initial encounter
S06325S Contusion and laceration of left cerebrum with loss of consciousness greater than 24 hours with 167 167 167 Yes Yes Yes No
return to pre-existing conscious level, sequela
S06326A Contusion and laceration of left cerebrum with loss of consciousness greater than 24 hours without 166 166 166 Yes Yes Yes No
return to pre-existing conscious level with patient surviving, initial encounter
S06326S Contusion and laceration of left cerebrum with loss of consciousness greater than 24 hours without 167 167 167 Yes Yes Yes No
return to pre-existing conscious level with patient surviving, sequela
S06329A Contusion and laceration of left cerebrum with loss of consciousness of unspecified duration, initial 167 167 167 Yes Yes Yes No
encounter
S06329S Contusion and laceration of left cerebrum with loss of consciousness of unspecified duration, sequela 167 167 167 Yes Yes Yes No

S06330A Contusion and laceration of cerebrum, unspecified, without loss of consciousness, initial encounter 167 167 167 Yes Yes Yes No
S06330S Contusion and laceration of cerebrum, unspecified, without loss of consciousness, sequela 167 167 167 Yes Yes Yes No
S06331A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, 167 167 167 Yes Yes Yes No
initial encounter
S06331S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, 167 167 167 Yes Yes Yes No
sequela
S06332A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 167 167 167 Yes Yes Yes No
minutes, initial encounter

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 169 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S06332S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 167 167 167 Yes Yes Yes No
minutes, sequela
S06333A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 1 hour to 5 hours 166 166 166 Yes Yes Yes No
59 minutes, initial encounter
S06333S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 1 hour to 5 hours 167 167 167 Yes Yes Yes No
59 minutes, sequela
S06334A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, 166 166 166 Yes Yes Yes No
initial encounter
S06334S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, 167 167 167 Yes Yes Yes No
sequela
S06335A Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours 166 166 166 Yes Yes Yes No
with return to pre-existing conscious level, initial encounter
S06335S Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours 167 167 167 Yes Yes Yes No
with return to pre-existing conscious level, sequela
S06336A Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours 166 166 166 Yes Yes Yes No
without return to pre-existing conscious level with patient surviving, initial encounter
S06336S Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours 167 167 167 Yes Yes Yes No
without return to pre-existing conscious level with patient surviving, sequela
S06339A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of unspecified 167 167 167 Yes Yes Yes No
duration, initial encounter
S06339S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of unspecified 167 167 167 Yes Yes Yes No
duration, sequela
S06340A Traumatic hemorrhage of right cerebrum without loss of consciousness, initial encounter 167 167 167 Yes Yes Yes No
S06340S Traumatic hemorrhage of right cerebrum without loss of consciousness, sequela 167 167 167 Yes Yes Yes No
S06341A Traumatic hemorrhage of right cerebrum with loss of consciousness of 30 minutes or less, initial 167 167 167 Yes Yes Yes No
encounter
S06341S Traumatic hemorrhage of right cerebrum with loss of consciousness of 30 minutes or less, sequela 167 167 167 Yes Yes Yes No
S06342A Traumatic hemorrhage of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, 167 167 167 Yes Yes Yes No
initial encounter
S06342S Traumatic hemorrhage of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, 167 167 167 Yes Yes Yes No
sequela
S06343A Traumatic hemorrhage of right cerebrum with loss of consciousness of 1 hours to 5 hours 59 166 166 166 Yes Yes Yes No
minutes, initial encounter
S06343S Traumatic hemorrhage of right cerebrum with loss of consciousness of 1 hours to 5 hours 59 167 167 167 Yes Yes Yes No
minutes, sequela
S06344A Traumatic hemorrhage of right cerebrum with loss of consciousness of 6 hours to 24 hours, initial 166 166 166 Yes Yes Yes No
encounter
S06344S Traumatic hemorrhage of right cerebrum with loss of consciousness of 6 hours to 24 hours, sequela 167 167 167 Yes Yes Yes No
S06345A Traumatic hemorrhage of right cerebrum with loss of consciousness greater than 24 hours with 166 166 166 Yes Yes Yes No
return to pre-existing conscious level, initial encounter
S06345S Traumatic hemorrhage of right cerebrum with loss of consciousness greater than 24 hours with 167 167 167 Yes Yes Yes No
return to pre-existing conscious level, sequela
S06346A Traumatic hemorrhage of right cerebrum with loss of consciousness greater than 24 hours without 166 166 166 Yes Yes Yes No
return to pre-existing conscious level with patient surviving, initial encounter
S06346S Traumatic hemorrhage of right cerebrum with loss of consciousness greater than 24 hours without 167 167 167 Yes Yes Yes No
return to pre-existing conscious level with patient surviving, sequela
S06349A Traumatic hemorrhage of right cerebrum with loss of consciousness of unspecified duration, initial 167 167 167 Yes Yes Yes No
encounter
S06349S Traumatic hemorrhage of right cerebrum with loss of consciousness of unspecified duration, sequela 167 167 167 Yes Yes Yes No
S06350A Traumatic hemorrhage of left cerebrum without loss of consciousness, initial encounter 167 167 167 Yes Yes Yes No
S06350S Traumatic hemorrhage of left cerebrum without loss of consciousness, sequela 167 167 167 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 170 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S06351A Traumatic hemorrhage of left cerebrum with loss of consciousness of 30 minutes or less, initial 167 167 167 Yes Yes Yes No
encounter
S06351S Traumatic hemorrhage of left cerebrum with loss of consciousness of 30 minutes or less, sequela 167 167 167 Yes Yes Yes No
S06352A Traumatic hemorrhage of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, 167 167 167 Yes Yes Yes No
initial encounter
S06352S Traumatic hemorrhage of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, 167 167 167 Yes Yes Yes No
sequela
S06353A Traumatic hemorrhage of left cerebrum with loss of consciousness of 1 hours to 5 hours 59 minutes, 166 166 166 Yes Yes Yes No
initial encounter
S06353S Traumatic hemorrhage of left cerebrum with loss of consciousness of 1 hours to 5 hours 59 minutes, 167 167 167 Yes Yes Yes No
sequela
S06354A Traumatic hemorrhage of left cerebrum with loss of consciousness of 6 hours to 24 hours, initial 166 166 166 Yes Yes Yes No
encounter
S06354S Traumatic hemorrhage of left cerebrum with loss of consciousness of 6 hours to 24 hours, sequela 167 167 167 Yes Yes Yes No
S06355A Traumatic hemorrhage of left cerebrum with loss of consciousness greater than 24 hours with return 166 166 166 Yes Yes Yes No
to pre-existing conscious level, initial encounter
S06355S Traumatic hemorrhage of left cerebrum with loss of consciousness greater than 24 hours with return 167 167 167 Yes Yes Yes No
to pre-existing conscious level, sequela
S06356A Traumatic hemorrhage of left cerebrum with loss of consciousness greater than 24 hours without 166 166 166 Yes Yes Yes No
return to pre-existing conscious level with patient surviving, initial encounter
S06356S Traumatic hemorrhage of left cerebrum with loss of consciousness greater than 24 hours without 167 167 167 Yes Yes Yes No
return to pre-existing conscious level with patient surviving, sequela
S06359A Traumatic hemorrhage of left cerebrum with loss of consciousness of unspecified duration, initial 167 167 167 Yes Yes Yes No
encounter
S06359S Traumatic hemorrhage of left cerebrum with loss of consciousness of unspecified duration, sequela 167 167 167 Yes Yes Yes No
S06360A Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, initial encounter 167 167 167 Yes Yes Yes No
S06360S Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, sequela 167 167 167 Yes Yes Yes No
S06361A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, 167 167 167 Yes Yes Yes No
initial encounter
S06361S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, 167 167 167 Yes Yes Yes No
sequela
S06362A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 167 167 167 Yes Yes Yes No
minutes, initial encounter
S06362S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 167 167 167 Yes Yes Yes No
minutes, sequela
S06363A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 1 hours to 5 hours 59 166 166 166 Yes Yes Yes No
minutes, initial encounter
S06363S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 1 hours to 5 hours 59 167 167 167 Yes Yes Yes No
minutes, sequela
S06364A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, 166 166 166 Yes Yes Yes No
initial encounter
S06364S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, 167 167 167 Yes Yes Yes No
sequela
S06365A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours 166 166 166 Yes Yes Yes No
with return to pre-existing conscious level, initial encounter
S06365S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours 167 167 167 Yes Yes Yes No
with return to pre-existing conscious level, sequela
S06366A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours 166 166 166 Yes Yes Yes No
without return to pre-existing conscious level with patient surviving, initial encounter
S06366S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours 167 167 167 Yes Yes Yes No
without return to pre-existing conscious level with patient surviving, sequela

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 171 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S06369A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of unspecified duration, 167 167 167 Yes Yes Yes No
initial encounter
S06369S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of unspecified duration, 167 167 167 Yes Yes Yes No
sequela
S06370A Contusion, laceration, and hemorrhage of cerebellum without loss of consciousness, initial encounter 167 167 167 Yes Yes Yes No

S06370S Contusion, laceration, and hemorrhage of cerebellum without loss of consciousness, sequela 167 167 167 Yes Yes Yes No
S06371A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 30 minutes or 167 167 167 Yes Yes Yes No
less, initial encounter
S06371S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 30 minutes or 167 167 167 Yes Yes Yes No
less, sequela
S06372A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 31 minutes to 59 167 167 167 Yes Yes Yes No
minutes, initial encounter
S06372S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 31 minutes to 59 167 167 167 Yes Yes Yes No
minutes, sequela
S06373A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 1 hour to 5 hours 166 166 166 Yes Yes Yes No
59 minutes, initial encounter
S06373S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 1 hour to 5 hours 167 167 167 Yes Yes Yes No
59 minutes, sequela
S06374A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 6 hours to 24 166 166 166 Yes Yes Yes No
hours, initial encounter
S06374S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 6 hours to 24 167 167 167 Yes Yes Yes No
hours, sequela
S06375A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness greater than 24 166 166 166 Yes Yes Yes No
hours with return to pre-existing conscious level, initial encounter
S06375S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness greater than 24 167 167 167 Yes Yes Yes No
hours with return to pre-existing conscious level, sequela
S06376A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness greater than 24 166 166 166 Yes Yes Yes No
hours without return to pre-existing conscious level with patient surviving, initial encounter
S06376S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness greater than 24 167 167 167 Yes Yes Yes No
hours without return to pre-existing conscious level with patient surviving, sequela
S06379A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of unspecified 167 167 167 Yes Yes Yes No
duration, initial encounter
S06379S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of unspecified 167 167 167 Yes Yes Yes No
duration, sequela
S06380A Contusion, laceration, and hemorrhage of brainstem without loss of consciousness, initial encounter 167 167 167 Yes Yes Yes No
S06380S Contusion, laceration, and hemorrhage of brainstem without loss of consciousness, sequela 167 167 167 Yes Yes Yes No
S06381A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 30 minutes or less, 167 167 167 Yes Yes Yes No
initial encounter
S06381S Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 30 minutes or less, 167 167 167 Yes Yes Yes No
sequela
S06382A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 31 minutes to 59 167 167 167 Yes Yes Yes No
minutes, initial encounter
S06382S Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 31 minutes to 59 167 167 167 Yes Yes Yes No
minutes, sequela
S06383A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 1 hour to 5 hours 166 166 166 Yes Yes Yes No
59 minutes, initial encounter
S06383S Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 1 hour to 5 hours 167 167 167 Yes Yes Yes No
59 minutes, sequela
S06384A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 6 hours to 24 166 166 166 Yes Yes Yes No
hours, initial encounter

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 172 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S06384S Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 6 hours to 24 167 167 167 Yes Yes Yes No
hours, sequela
S06385A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness greater than 24 166 166 166 Yes Yes Yes No
hours with return to pre-existing conscious level, initial encounter
S06385S Contusion, laceration, and hemorrhage of brainstem with loss of consciousness greater than 24 167 167 167 Yes Yes Yes No
hours with return to pre-existing conscious level, sequela
S06386A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness greater than 24 166 166 166 Yes Yes Yes No
hours without return to pre-existing conscious level with patient surviving, initial encounter
S06386S Contusion, laceration, and hemorrhage of brainstem with loss of consciousness greater than 24 167 167 167 Yes Yes Yes No
hours without return to pre-existing conscious level with patient surviving, sequela
S06389A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of unspecified 167 167 167 Yes Yes Yes No
duration, initial encounter
S06389S Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of unspecified 167 167 167 Yes Yes Yes No
duration, sequela
S064X0A Epidural hemorrhage without loss of consciousness, initial encounter 167 167 167 Yes Yes Yes No
S064X0S Epidural hemorrhage without loss of consciousness, sequela 167 167 167 Yes Yes Yes No
S064X1A Epidural hemorrhage with loss of consciousness of 30 minutes or less, initial encounter 167 167 167 Yes Yes Yes No
S064X1S Epidural hemorrhage with loss of consciousness of 30 minutes or less, sequela 167 167 167 Yes Yes Yes No
S064X2A Epidural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, initial encounter 167 167 167 Yes Yes Yes No
S064X2S Epidural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, sequela 167 167 167 Yes Yes Yes No
S064X3A Epidural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter 166 166 166 Yes Yes Yes No
S064X3S Epidural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela 167 167 167 Yes Yes Yes No
S064X4A Epidural hemorrhage with loss of consciousness of 6 hours to 24 hours, initial encounter 166 166 166 Yes Yes Yes No
S064X4S Epidural hemorrhage with loss of consciousness of 6 hours to 24 hours, sequela 167 167 167 Yes Yes Yes No
S064X5A Epidural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing 166 166 166 Yes Yes Yes No
conscious level, initial encounter
S064X5S Epidural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing 167 167 167 Yes Yes Yes No
conscious level, sequela
S064X6A Epidural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing 166 166 166 Yes Yes Yes No
conscious level with patient surviving, initial encounter
S064X6S Epidural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing 167 167 167 Yes Yes Yes No
conscious level with patient surviving, sequela
S064X9A Epidural hemorrhage with loss of consciousness of unspecified duration, initial encounter 167 167 167 Yes Yes Yes No
S064X9S Epidural hemorrhage with loss of consciousness of unspecified duration, sequela 167 167 167 Yes Yes Yes No
S065X0A Traumatic subdural hemorrhage without loss of consciousness, initial encounter 167 167 167 Yes Yes Yes No
S065X0S Traumatic subdural hemorrhage without loss of consciousness, sequela 167 167 167 Yes Yes Yes No
S065X1A Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, initial encounter 167 167 167 Yes Yes Yes No
S065X1S Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, sequela 167 167 167 Yes Yes Yes No
S065X2A Traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, initial 167 167 167 Yes Yes Yes No
encounter
S065X2S Traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, sequela 167 167 167 Yes Yes Yes No
S065X3A Traumatic subdural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, initial 166 166 166 Yes Yes Yes No
encounter
S065X3S Traumatic subdural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela 167 167 167 Yes Yes Yes No
S065X4A Traumatic subdural hemorrhage with loss of consciousness of 6 hours to 24 hours, initial encounter 166 166 166 Yes Yes Yes No
S065X4S Traumatic subdural hemorrhage with loss of consciousness of 6 hours to 24 hours, sequela 167 167 167 Yes Yes Yes No
S065X5A Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours with return to pre- 166 166 166 Yes Yes Yes No
existing conscious level, initial encounter
S065X5S Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours with return to pre- 167 167 167 Yes Yes Yes No
existing conscious level, sequela

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 173 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S065X6A Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours without return to 166 166 166 Yes Yes Yes No
pre-existing conscious level with patient surviving, initial encounter
S065X6S Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours without return to 167 167 167 Yes Yes Yes No
pre-existing conscious level with patient surviving, sequela
S065X9A Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter 167 167 167 Yes Yes Yes No
S065X9S Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, sequela 167 167 167 Yes Yes Yes No
S066X0A Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter 167 167 167 Yes Yes Yes No
S066X0S Traumatic subarachnoid hemorrhage without loss of consciousness, sequela 167 167 167 Yes Yes Yes No
S066X1A Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, initial 167 167 167 Yes Yes Yes No
encounter
S066X1S Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, sequela 167 167 167 Yes Yes Yes No
S066X2A Traumatic subarachnoid hemorrhage with loss of consciousness of 31 minutes to 59 minutes, initial 167 167 167 Yes Yes Yes No
encounter
S066X2S Traumatic subarachnoid hemorrhage with loss of consciousness of 31 minutes to 59 minutes, 167 167 167 Yes Yes Yes No
sequela
S066X3A Traumatic subarachnoid hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, 166 166 166 Yes Yes Yes No
initial encounter
S066X3S Traumatic subarachnoid hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, 167 167 167 Yes Yes Yes No
sequela
S066X4A Traumatic subarachnoid hemorrhage with loss of consciousness of 6 hours to 24 hours, initial 166 166 166 Yes Yes Yes No
encounter
S066X4S Traumatic subarachnoid hemorrhage with loss of consciousness of 6 hours to 24 hours, sequela 167 167 167 Yes Yes Yes No
S066X5A Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours with return to 166 166 166 Yes Yes Yes No
pre-existing conscious level, initial encounter
S066X5S Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours with return to 167 167 167 Yes Yes Yes No
pre-existing conscious level, sequela
S066X6A Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours without 166 166 166 Yes Yes Yes No
return to pre-existing conscious level with patient surviving, initial encounter
S066X6S Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours without 167 167 167 Yes Yes Yes No
return to pre-existing conscious level with patient surviving, sequela
S066X9A Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, initial 167 167 167 Yes Yes Yes No
encounter
S066X9S Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, sequela 167 167 167 Yes Yes Yes No
S06810A Injury of right internal carotid artery, intracranial portion, not elsewhere classified without loss of 167 167 167 Yes Yes Yes No
consciousness, initial encounter
S06810S Injury of right internal carotid artery, intracranial portion, not elsewhere classified without loss of 167 167 167 Yes Yes Yes No
consciousness, sequela
S06811A Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness of 30 minutes or less, initial encounter
S06811S Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness of 30 minutes or less, sequela
S06812A Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness of 31 minutes to 59 minutes, initial encounter
S06812S Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness of 31 minutes to 59 minutes, sequela
S06813A Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of 166 166 166 Yes Yes Yes No
consciousness of 1 hour to 5 hours 59 minutes, initial encounter
S06813S Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness of 1 hour to 5 hours 59 minutes, sequela
S06814A Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of 166 166 166 Yes Yes Yes No
consciousness of 6 hours to 24 hours, initial encounter

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 174 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S06814S Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness of 6 hours to 24 hours, sequela
S06815A Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of 166 166 166 Yes Yes Yes No
consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
S06815S Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness greater than 24 hours with return to pre-existing conscious level, sequela
S06816A Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of 166 166 166 Yes Yes Yes No
consciousness greater than 24 hours without return to pre-existing conscious level with patient
surviving, initial encounter
S06816S Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness greater than 24 hours without return to pre-existing conscious level with patient
surviving, sequela
S06819A Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness of unspecified duration, initial encounter
S06819S Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness of unspecified duration, sequela
S06820A Injury of left internal carotid artery, intracranial portion, not elsewhere classified without loss of 167 167 167 Yes Yes Yes No
consciousness, initial encounter
S06820S Injury of left internal carotid artery, intracranial portion, not elsewhere classified without loss of 167 167 167 Yes Yes Yes No
consciousness, sequela
S06821A Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness of 30 minutes or less, initial encounter
S06821S Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness of 30 minutes or less, sequela
S06822A Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness of 31 minutes to 59 minutes, initial encounter
S06822S Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness of 31 minutes to 59 minutes, sequela
S06823A Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of 166 166 166 Yes Yes Yes No
consciousness of 1 hour to 5 hours 59 minutes, initial encounter
S06823S Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness of 1 hour to 5 hours 59 minutes, sequela
S06824A Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of 166 166 166 Yes Yes Yes No
consciousness of 6 hours to 24 hours, initial encounter
S06824S Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness of 6 hours to 24 hours, sequela
S06825A Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of 166 166 166 Yes Yes Yes No
consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
S06825S Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness greater than 24 hours with return to pre-existing conscious level, sequela
S06826A Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of 166 166 166 Yes Yes Yes No
consciousness greater than 24 hours without return to pre-existing conscious level with patient
surviving, initial encounter
S06826S Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness greater than 24 hours without return to pre-existing conscious level with patient
surviving, sequela
S06829A Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness of unspecified duration, initial encounter
S06829S Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of 167 167 167 Yes Yes Yes No
consciousness of unspecified duration, sequela
S06890A Other specified intracranial injury without loss of consciousness, initial encounter 167 167 167 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 175 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S06890S Other specified intracranial injury without loss of consciousness, sequela 167 167 167 Yes Yes Yes No
S06891A Other specified intracranial injury with loss of consciousness of 30 minutes or less, initial encounter 167 167 167 Yes Yes Yes No
S06891S Other specified intracranial injury with loss of consciousness of 30 minutes or less, sequela 167 167 167 Yes Yes Yes No
S06892A Other specified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, initial 167 167 167 Yes Yes Yes No
encounter
S06892S Other specified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, sequela 167 167 167 Yes Yes Yes No
S06893A Other specified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, initial 166 166 166 Yes Yes Yes No
encounter
S06893S Other specified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela 167 167 167 Yes Yes Yes No

S06894A Other specified intracranial injury with loss of consciousness of 6 hours to 24 hours, initial encounter 166 166 166 Yes Yes Yes No
S06894S Other specified intracranial injury with loss of consciousness of 6 hours to 24 hours, sequela 167 167 167 Yes Yes Yes No
S06895A Other specified intracranial injury with loss of consciousness greater than 24 hours with return to 166 166 166 Yes Yes Yes No
pre-existing conscious level, initial encounter
S06895S Other specified intracranial injury with loss of consciousness greater than 24 hours with return to 167 167 167 Yes Yes Yes No
pre-existing conscious level, sequela
S06896A Other specified intracranial injury with loss of consciousness greater than 24 hours without return to 166 166 166 Yes Yes Yes No
pre-existing conscious level with patient surviving, initial encounter
S06896S Other specified intracranial injury with loss of consciousness greater than 24 hours without return to 167 167 167 Yes Yes Yes No
pre-existing conscious level with patient surviving, sequela
S06899A Other specified intracranial injury with loss of consciousness of unspecified duration, initial 167 167 167 Yes Yes Yes No
encounter
S06899S Other specified intracranial injury with loss of consciousness of unspecified duration, sequela 167 167 167 Yes Yes Yes No
S069X0A Unspecified intracranial injury without loss of consciousness, initial encounter 167 167 167 Yes Yes Yes No
S069X0S Unspecified intracranial injury without loss of consciousness, sequela 167 167 167 Yes Yes Yes No
S069X1A Unspecified intracranial injury with loss of consciousness of 30 minutes or less, initial encounter 167 167 167 Yes Yes Yes No
S069X1S Unspecified intracranial injury with loss of consciousness of 30 minutes or less, sequela 167 167 167 Yes Yes Yes No
S069X2A Unspecified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, initial 167 167 167 Yes Yes Yes No
encounter
S069X2S Unspecified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, sequela 167 167 167 Yes Yes Yes No
S069X3A Unspecified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, initial 166 166 166 Yes Yes Yes No
encounter
S069X3S Unspecified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela 167 167 167 Yes Yes Yes No
S069X4A Unspecified intracranial injury with loss of consciousness of 6 hours to 24 hours, initial encounter 166 166 166 Yes Yes Yes No
S069X4S Unspecified intracranial injury with loss of consciousness of 6 hours to 24 hours, sequela 167 167 167 Yes Yes Yes No
S069X5A Unspecified intracranial injury with loss of consciousness greater than 24 hours with return to pre- 166 166 166 Yes Yes Yes No
existing conscious level, initial encounter
S069X5S Unspecified intracranial injury with loss of consciousness greater than 24 hours with return to pre- 167 167 167 Yes Yes Yes No
existing conscious level, sequela
S069X6A Unspecified intracranial injury with loss of consciousness greater than 24 hours without return to 166 166 166 Yes Yes Yes No
pre-existing conscious level with patient surviving, initial encounter
S069X6S Unspecified intracranial injury with loss of consciousness greater than 24 hours without return to 167 167 167 Yes Yes Yes No
pre-existing conscious level with patient surviving, sequela
S069X9A Unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter 167 167 167 Yes Yes Yes No
S069X9S Unspecified intracranial injury with loss of consciousness of unspecified duration, sequela 167 167 167 Yes Yes Yes No
S12000A Unspecified displaced fracture of first cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12000B Unspecified displaced fracture of first cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12001A Unspecified nondisplaced fracture of first cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12001B Unspecified nondisplaced fracture of first cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S1201XA Stable burst fracture of first cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S1201XB Stable burst fracture of first cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 176 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S1202XA Unstable burst fracture of first cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S1202XB Unstable burst fracture of first cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12030A Displaced posterior arch fracture of first cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12030B Displaced posterior arch fracture of first cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12031A Nondisplaced posterior arch fracture of first cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12031B Nondisplaced posterior arch fracture of first cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12040A Displaced lateral mass fracture of first cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12040B Displaced lateral mass fracture of first cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12041A Nondisplaced lateral mass fracture of first cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12041B Nondisplaced lateral mass fracture of first cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12090A Other displaced fracture of first cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12090B Other displaced fracture of first cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12091A Other nondisplaced fracture of first cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12091B Other nondisplaced fracture of first cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12100A Unspecified displaced fracture of second cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12100B Unspecified displaced fracture of second cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12101A Unspecified nondisplaced fracture of second cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12101B Unspecified nondisplaced fracture of second cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12110A Anterior displaced Type II dens fracture, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12110B Anterior displaced Type II dens fracture, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12111A Posterior displaced Type II dens fracture, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12111B Posterior displaced Type II dens fracture, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12112A Nondisplaced Type II dens fracture, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12112B Nondisplaced Type II dens fracture, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12120A Other displaced dens fracture, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12120B Other displaced dens fracture, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12121A Other nondisplaced dens fracture, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12121B Other nondisplaced dens fracture, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12130A Unspecified traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
closed fracture
S12130B Unspecified traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
open fracture
S12131A Unspecified traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial encounter 169 169 169 Yes Yes Yes No
for closed fracture
S12131B Unspecified traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial encounter 169 169 169 Yes Yes Yes No
for open fracture
S1214XA Type III traumatic spondylolisthesis of second cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S1214XB Type III traumatic spondylolisthesis of second cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12150A Other traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for closed 169 169 169 Yes Yes Yes No
fracture
S12150B Other traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for open 169 169 169 Yes Yes Yes No
fracture
S12151A Other traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
closed fracture
S12151B Other traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
open fracture
S12190A Other displaced fracture of second cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12190B Other displaced fracture of second cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12191A Other nondisplaced fracture of second cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12191B Other nondisplaced fracture of second cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12200A Unspecified displaced fracture of third cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 177 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S12200B Unspecified displaced fracture of third cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12201A Unspecified nondisplaced fracture of third cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12201B Unspecified nondisplaced fracture of third cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12230A Unspecified traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
closed fracture
S12230B Unspecified traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
open fracture
S12231A Unspecified traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
closed fracture
S12231B Unspecified traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
open fracture
S1224XA Type III traumatic spondylolisthesis of third cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S1224XB Type III traumatic spondylolisthesis of third cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12250A Other traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for closed 169 169 169 Yes Yes Yes No
fracture
S12250B Other traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for open 169 169 169 Yes Yes Yes No
fracture
S12251A Other traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial encounter for closed 169 169 169 Yes Yes Yes No
fracture
S12251B Other traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial encounter for open 169 169 169 Yes Yes Yes No
fracture
S12290A Other displaced fracture of third cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12290B Other displaced fracture of third cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12291A Other nondisplaced fracture of third cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12291B Other nondisplaced fracture of third cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12300A Unspecified displaced fracture of fourth cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12300B Unspecified displaced fracture of fourth cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12301A Unspecified nondisplaced fracture of fourth cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12301B Unspecified nondisplaced fracture of fourth cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12330A Unspecified traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
closed fracture
S12330B Unspecified traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
open fracture
S12331A Unspecified traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
closed fracture
S12331B Unspecified traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
open fracture
S1234XA Type III traumatic spondylolisthesis of fourth cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S1234XB Type III traumatic spondylolisthesis of fourth cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12350A Other traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for closed 169 169 169 Yes Yes Yes No
fracture
S12350B Other traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for open 169 169 169 Yes Yes Yes No
fracture
S12351A Other traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
closed fracture
S12351B Other traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial encounter for open 169 169 169 Yes Yes Yes No
fracture
S12390A Other displaced fracture of fourth cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12390B Other displaced fracture of fourth cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12391A Other nondisplaced fracture of fourth cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12391B Other nondisplaced fracture of fourth cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 178 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S12400A Unspecified displaced fracture of fifth cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12400B Unspecified displaced fracture of fifth cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12401A Unspecified nondisplaced fracture of fifth cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12401B Unspecified nondisplaced fracture of fifth cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12430A Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
closed fracture
S12430B Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for open 169 169 169 Yes Yes Yes No
fracture
S12431A Unspecified traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
closed fracture
S12431B Unspecified traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
open fracture
S1244XA Type III traumatic spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S1244XB Type III traumatic spondylolisthesis of fifth cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12450A Other traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed 169 169 169 Yes Yes Yes No
fracture
S12450B Other traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for open 169 169 169 Yes Yes Yes No
fracture
S12451A Other traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed 169 169 169 Yes Yes Yes No
fracture
S12451B Other traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for open 169 169 169 Yes Yes Yes No
fracture
S12490A Other displaced fracture of fifth cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12490B Other displaced fracture of fifth cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12491A Other nondisplaced fracture of fifth cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12491B Other nondisplaced fracture of fifth cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12500A Unspecified displaced fracture of sixth cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12500B Unspecified displaced fracture of sixth cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12501A Unspecified nondisplaced fracture of sixth cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12501B Unspecified nondisplaced fracture of sixth cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12530A Unspecified traumatic displaced spondylolisthesis of sixth cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
closed fracture
S12530B Unspecified traumatic displaced spondylolisthesis of sixth cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
open fracture
S12531A Unspecified traumatic nondisplaced spondylolisthesis of sixth cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
closed fracture
S12531B Unspecified traumatic nondisplaced spondylolisthesis of sixth cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
open fracture
S1254XA Type III traumatic spondylolisthesis of sixth cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S1254XB Type III traumatic spondylolisthesis of sixth cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12550A Other traumatic displaced spondylolisthesis of sixth cervical vertebra, initial encounter for closed 169 169 169 Yes Yes Yes No
fracture
S12550B Other traumatic displaced spondylolisthesis of sixth cervical vertebra, initial encounter for open 169 169 169 Yes Yes Yes No
fracture
S12551A Other traumatic nondisplaced spondylolisthesis of sixth cervical vertebra, initial encounter for closed 169 169 169 Yes Yes Yes No
fracture
S12551B Other traumatic nondisplaced spondylolisthesis of sixth cervical vertebra, initial encounter for open 169 169 169 Yes Yes Yes No
fracture
S12590A Other displaced fracture of sixth cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12590B Other displaced fracture of sixth cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12591A Other nondisplaced fracture of sixth cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 179 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S12591B Other nondisplaced fracture of sixth cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12600A Unspecified displaced fracture of seventh cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12600B Unspecified displaced fracture of seventh cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12601A Unspecified nondisplaced fracture of seventh cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12601B Unspecified nondisplaced fracture of seventh cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12630A Unspecified traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
closed fracture
S12630B Unspecified traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
open fracture
S12631A Unspecified traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial encounter 169 169 169 Yes Yes Yes No
for closed fracture
S12631B Unspecified traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial encounter 169 169 169 Yes Yes Yes No
for open fracture
S1264XA Type III traumatic spondylolisthesis of seventh cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S1264XB Type III traumatic spondylolisthesis of seventh cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12650A Other traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for closed 169 169 169 Yes Yes Yes No
fracture
S12650B Other traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for open 169 169 169 Yes Yes Yes No
fracture
S12651A Other traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
closed fracture
S12651B Other traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial encounter for 169 169 169 Yes Yes Yes No
open fracture
S12690A Other displaced fracture of seventh cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12690B Other displaced fracture of seventh cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S12691A Other nondisplaced fracture of seventh cervical vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S12691B Other nondisplaced fracture of seventh cervical vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S128XXA Fracture of other parts of neck, initial encounter 169 169 169 Yes Yes Yes No
S129XXA Fracture of neck, unspecified, initial encounter 169 169 169 Yes Yes Yes No
S140XXA Concussion and edema of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S140XXD Concussion and edema of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S140XXS Concussion and edema of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14101A Unspecified injury at C1 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14101D Unspecified injury at C1 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14101S Unspecified injury at C1 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14102A Unspecified injury at C2 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14102D Unspecified injury at C2 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14102S Unspecified injury at C2 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14103A Unspecified injury at C3 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14103D Unspecified injury at C3 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14103S Unspecified injury at C3 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14104A Unspecified injury at C4 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14104D Unspecified injury at C4 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14104S Unspecified injury at C4 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14105A Unspecified injury at C5 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14105D Unspecified injury at C5 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14105S Unspecified injury at C5 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14106A Unspecified injury at C6 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14106D Unspecified injury at C6 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14106S Unspecified injury at C6 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14107A Unspecified injury at C7 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 180 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S14107D Unspecified injury at C7 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14107S Unspecified injury at C7 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14108A Unspecified injury at C8 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14108D Unspecified injury at C8 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14108S Unspecified injury at C8 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14109A Unspecified injury at unspecified level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14109D Unspecified injury at unspecified level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14109S Unspecified injury at unspecified level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14111A Complete lesion at C1 level of cervical spinal cord, initial encounter 70 70 70 Yes Yes Yes No
S14111D Complete lesion at C1 level of cervical spinal cord, subsequent encounter 70 70 70 Yes Yes Yes No
S14111S Complete lesion at C1 level of cervical spinal cord, sequela 70 70 70 Yes Yes Yes No
S14112A Complete lesion at C2 level of cervical spinal cord, initial encounter 70 70 70 Yes Yes Yes No
S14112D Complete lesion at C2 level of cervical spinal cord, subsequent encounter 70 70 70 Yes Yes Yes No
S14112S Complete lesion at C2 level of cervical spinal cord, sequela 70 70 70 Yes Yes Yes No
S14113A Complete lesion at C3 level of cervical spinal cord, initial encounter 70 70 70 Yes Yes Yes No
S14113D Complete lesion at C3 level of cervical spinal cord, subsequent encounter 70 70 70 Yes Yes Yes No
S14113S Complete lesion at C3 level of cervical spinal cord, sequela 70 70 70 Yes Yes Yes No
S14114A Complete lesion at C4 level of cervical spinal cord, initial encounter 70 70 70 Yes Yes Yes No
S14114D Complete lesion at C4 level of cervical spinal cord, subsequent encounter 70 70 70 Yes Yes Yes No
S14114S Complete lesion at C4 level of cervical spinal cord, sequela 70 70 70 Yes Yes Yes No
S14115A Complete lesion at C5 level of cervical spinal cord, initial encounter 70 70 70 Yes Yes Yes No
S14115D Complete lesion at C5 level of cervical spinal cord, subsequent encounter 70 70 70 Yes Yes Yes No
S14115S Complete lesion at C5 level of cervical spinal cord, sequela 70 70 70 Yes Yes Yes No
S14116A Complete lesion at C6 level of cervical spinal cord, initial encounter 70 70 70 Yes Yes Yes No
S14116D Complete lesion at C6 level of cervical spinal cord, subsequent encounter 70 70 70 Yes Yes Yes No
S14116S Complete lesion at C6 level of cervical spinal cord, sequela 70 70 70 Yes Yes Yes No
S14117A Complete lesion at C7 level of cervical spinal cord, initial encounter 70 70 70 Yes Yes Yes No
S14117D Complete lesion at C7 level of cervical spinal cord, subsequent encounter 70 70 70 Yes Yes Yes No
S14117S Complete lesion at C7 level of cervical spinal cord, sequela 70 70 70 Yes Yes Yes No
S14118A Complete lesion at C8 level of cervical spinal cord, initial encounter 70 70 70 Yes Yes Yes No
S14118D Complete lesion at C8 level of cervical spinal cord, subsequent encounter 70 70 70 Yes Yes Yes No
S14118S Complete lesion at C8 level of cervical spinal cord, sequela 70 70 70 Yes Yes Yes No
S14119A Complete lesion at unspecified level of cervical spinal cord, initial encounter 70 70 70 Yes Yes Yes No
S14119D Complete lesion at unspecified level of cervical spinal cord, subsequent encounter 70 70 70 Yes Yes Yes No
S14119S Complete lesion at unspecified level of cervical spinal cord, sequela 70 70 70 Yes Yes Yes No
S14121A Central cord syndrome at C1 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14121D Central cord syndrome at C1 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14121S Central cord syndrome at C1 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14122A Central cord syndrome at C2 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14122D Central cord syndrome at C2 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14122S Central cord syndrome at C2 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14123A Central cord syndrome at C3 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14123D Central cord syndrome at C3 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14123S Central cord syndrome at C3 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14124A Central cord syndrome at C4 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14124D Central cord syndrome at C4 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14124S Central cord syndrome at C4 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14125A Central cord syndrome at C5 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14125D Central cord syndrome at C5 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14125S Central cord syndrome at C5 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14126A Central cord syndrome at C6 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 181 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S14126D Central cord syndrome at C6 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14126S Central cord syndrome at C6 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14127A Central cord syndrome at C7 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14127D Central cord syndrome at C7 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14127S Central cord syndrome at C7 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14128A Central cord syndrome at C8 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14128D Central cord syndrome at C8 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14128S Central cord syndrome at C8 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14129A Central cord syndrome at unspecified level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14129D Central cord syndrome at unspecified level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14129S Central cord syndrome at unspecified level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14131A Anterior cord syndrome at C1 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14131D Anterior cord syndrome at C1 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14131S Anterior cord syndrome at C1 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14132A Anterior cord syndrome at C2 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14132D Anterior cord syndrome at C2 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14132S Anterior cord syndrome at C2 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14133A Anterior cord syndrome at C3 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14133D Anterior cord syndrome at C3 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14133S Anterior cord syndrome at C3 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14134A Anterior cord syndrome at C4 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14134D Anterior cord syndrome at C4 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14134S Anterior cord syndrome at C4 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14135A Anterior cord syndrome at C5 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14135D Anterior cord syndrome at C5 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14135S Anterior cord syndrome at C5 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14136A Anterior cord syndrome at C6 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14136D Anterior cord syndrome at C6 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14136S Anterior cord syndrome at C6 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14137A Anterior cord syndrome at C7 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14137D Anterior cord syndrome at C7 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14137S Anterior cord syndrome at C7 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14138A Anterior cord syndrome at C8 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14138D Anterior cord syndrome at C8 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14138S Anterior cord syndrome at C8 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14139A Anterior cord syndrome at unspecified level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14139D Anterior cord syndrome at unspecified level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14139S Anterior cord syndrome at unspecified level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14141A Brown-Sequard syndrome at C1 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14141D Brown-Sequard syndrome at C1 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14141S Brown-Sequard syndrome at C1 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14142A Brown-Sequard syndrome at C2 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14142D Brown-Sequard syndrome at C2 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14142S Brown-Sequard syndrome at C2 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14143A Brown-Sequard syndrome at C3 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14143D Brown-Sequard syndrome at C3 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14143S Brown-Sequard syndrome at C3 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14144A Brown-Sequard syndrome at C4 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14144D Brown-Sequard syndrome at C4 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14144S Brown-Sequard syndrome at C4 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14145A Brown-Sequard syndrome at C5 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 182 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S14145D Brown-Sequard syndrome at C5 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14145S Brown-Sequard syndrome at C5 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14146A Brown-Sequard syndrome at C6 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14146D Brown-Sequard syndrome at C6 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14146S Brown-Sequard syndrome at C6 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14147A Brown-Sequard syndrome at C7 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14147D Brown-Sequard syndrome at C7 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14147S Brown-Sequard syndrome at C7 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14148A Brown-Sequard syndrome at C8 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14148D Brown-Sequard syndrome at C8 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14148S Brown-Sequard syndrome at C8 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14149A Brown-Sequard syndrome at unspecified level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14149D Brown-Sequard syndrome at unspecified level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14149S Brown-Sequard syndrome at unspecified level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14151A Other incomplete lesion at C1 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14151D Other incomplete lesion at C1 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14151S Other incomplete lesion at C1 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14152A Other incomplete lesion at C2 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14152D Other incomplete lesion at C2 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14152S Other incomplete lesion at C2 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14153A Other incomplete lesion at C3 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14153D Other incomplete lesion at C3 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14153S Other incomplete lesion at C3 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14154A Other incomplete lesion at C4 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14154D Other incomplete lesion at C4 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14154S Other incomplete lesion at C4 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14155A Other incomplete lesion at C5 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14155D Other incomplete lesion at C5 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14155S Other incomplete lesion at C5 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14156A Other incomplete lesion at C6 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14156D Other incomplete lesion at C6 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14156S Other incomplete lesion at C6 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14157A Other incomplete lesion at C7 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14157D Other incomplete lesion at C7 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14157S Other incomplete lesion at C7 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14158A Other incomplete lesion at C8 level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14158D Other incomplete lesion at C8 level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14158S Other incomplete lesion at C8 level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S14159A Other incomplete lesion at unspecified level of cervical spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S14159D Other incomplete lesion at unspecified level of cervical spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S14159S Other incomplete lesion at unspecified level of cervical spinal cord, sequela 72 72 72 Yes Yes Yes No
S22000A Wedge compression fracture of unspecified thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22000B Wedge compression fracture of unspecified thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22001A Stable burst fracture of unspecified thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22001B Stable burst fracture of unspecified thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22002A Unstable burst fracture of unspecified thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22002B Unstable burst fracture of unspecified thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22008A Other fracture of unspecified thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22008B Other fracture of unspecified thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22009A Unspecified fracture of unspecified thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22009B Unspecified fracture of unspecified thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 183 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S22010A Wedge compression fracture of first thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22010B Wedge compression fracture of first thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22011A Stable burst fracture of first thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22011B Stable burst fracture of first thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22012A Unstable burst fracture of first thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22012B Unstable burst fracture of first thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22018A Other fracture of first thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22018B Other fracture of first thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22019A Unspecified fracture of first thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22019B Unspecified fracture of first thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22020A Wedge compression fracture of second thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22020B Wedge compression fracture of second thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22021A Stable burst fracture of second thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22021B Stable burst fracture of second thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22022A Unstable burst fracture of second thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22022B Unstable burst fracture of second thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22028A Other fracture of second thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22028B Other fracture of second thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22029A Unspecified fracture of second thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22029B Unspecified fracture of second thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22030A Wedge compression fracture of third thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22030B Wedge compression fracture of third thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22031A Stable burst fracture of third thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22031B Stable burst fracture of third thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22032A Unstable burst fracture of third thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22032B Unstable burst fracture of third thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22038A Other fracture of third thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22038B Other fracture of third thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22039A Unspecified fracture of third thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22039B Unspecified fracture of third thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22040A Wedge compression fracture of fourth thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22040B Wedge compression fracture of fourth thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22041A Stable burst fracture of fourth thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22041B Stable burst fracture of fourth thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22042A Unstable burst fracture of fourth thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22042B Unstable burst fracture of fourth thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22048A Other fracture of fourth thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22048B Other fracture of fourth thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22049A Unspecified fracture of fourth thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22049B Unspecified fracture of fourth thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22050A Wedge compression fracture of T5-T6 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22050B Wedge compression fracture of T5-T6 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22051A Stable burst fracture of T5-T6 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22051B Stable burst fracture of T5-T6 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22052A Unstable burst fracture of T5-T6 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22052B Unstable burst fracture of T5-T6 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22058A Other fracture of T5-T6 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22058B Other fracture of T5-T6 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22059A Unspecified fracture of T5-T6 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22059B Unspecified fracture of T5-T6 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22060A Wedge compression fracture of T7-T8 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 184 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S22060B Wedge compression fracture of T7-T8 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22061A Stable burst fracture of T7-T8 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22061B Stable burst fracture of T7-T8 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22062A Unstable burst fracture of T7-T8 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22062B Unstable burst fracture of T7-T8 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22068A Other fracture of T7-T8 thoracic vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22068B Other fracture of T7-T8 thoracic vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22069A Unspecified fracture of T7-T8 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22069B Unspecified fracture of T7-T8 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22070A Wedge compression fracture of T9-T10 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22070B Wedge compression fracture of T9-T10 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22071A Stable burst fracture of T9-T10 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22071B Stable burst fracture of T9-T10 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22072A Unstable burst fracture of T9-T10 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22072B Unstable burst fracture of T9-T10 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22078A Other fracture of T9-T10 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22078B Other fracture of T9-T10 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22079A Unspecified fracture of T9-T10 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22079B Unspecified fracture of T9-T10 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22080A Wedge compression fracture of T11-T12 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22080B Wedge compression fracture of T11-T12 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22081A Stable burst fracture of T11-T12 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22081B Stable burst fracture of T11-T12 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22082A Unstable burst fracture of T11-T12 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22082B Unstable burst fracture of T11-T12 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22088A Other fracture of T11-T12 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22088B Other fracture of T11-T12 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S22089A Unspecified fracture of T11-T12 vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S22089B Unspecified fracture of T11-T12 vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S240XXA Concussion and edema of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S240XXD Concussion and edema of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S240XXS Concussion and edema of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24101A Unspecified injury at T1 level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24101D Unspecified injury at T1 level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24101S Unspecified injury at T1 level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24102A Unspecified injury at T2-T6 level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24102D Unspecified injury at T2-T6 level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24102S Unspecified injury at T2-T6 level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24103A Unspecified injury at T7-T10 level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24103D Unspecified injury at T7-T10 level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24103S Unspecified injury at T7-T10 level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24104A Unspecified injury at T11-T12 level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24104D Unspecified injury at T11-T12 level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24104S Unspecified injury at T11-T12 level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24109A Unspecified injury at unspecified level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24109D Unspecified injury at unspecified level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24109S Unspecified injury at unspecified level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24111A Complete lesion at T1 level of thoracic spinal cord, initial encounter 71 71 71 Yes Yes Yes No
S24111D Complete lesion at T1 level of thoracic spinal cord, subsequent encounter 71 71 71 Yes Yes Yes No
S24111S Complete lesion at T1 level of thoracic spinal cord, sequela 71 71 71 Yes Yes Yes No
S24112A Complete lesion at T2-T6 level of thoracic spinal cord, initial encounter 71 71 71 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 185 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S24112D Complete lesion at T2-T6 level of thoracic spinal cord, subsequent encounter 71 71 71 Yes Yes Yes No
S24112S Complete lesion at T2-T6 level of thoracic spinal cord, sequela 71 71 71 Yes Yes Yes No
S24113A Complete lesion at T7-T10 level of thoracic spinal cord, initial encounter 71 71 71 Yes Yes Yes No
S24113D Complete lesion at T7-T10 level of thoracic spinal cord, subsequent encounter 71 71 71 Yes Yes Yes No
S24113S Complete lesion at T7-T10 level of thoracic spinal cord, sequela 71 71 71 Yes Yes Yes No
S24114A Complete lesion at T11-T12 level of thoracic spinal cord, initial encounter 71 71 71 Yes Yes Yes No
S24114D Complete lesion at T11-T12 level of thoracic spinal cord, subsequent encounter 71 71 71 Yes Yes Yes No
S24114S Complete lesion at T11-T12 level of thoracic spinal cord, sequela 71 71 71 Yes Yes Yes No
S24119A Complete lesion at unspecified level of thoracic spinal cord, initial encounter 71 71 71 Yes Yes Yes No
S24119D Complete lesion at unspecified level of thoracic spinal cord, subsequent encounter 71 71 71 Yes Yes Yes No
S24119S Complete lesion at unspecified level of thoracic spinal cord, sequela 71 71 71 Yes Yes Yes No
S24131A Anterior cord syndrome at T1 level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24131D Anterior cord syndrome at T1 level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24131S Anterior cord syndrome at T1 level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24132A Anterior cord syndrome at T2-T6 level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24132D Anterior cord syndrome at T2-T6 level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24132S Anterior cord syndrome at T2-T6 level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24133A Anterior cord syndrome at T7-T10 level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24133D Anterior cord syndrome at T7-T10 level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24133S Anterior cord syndrome at T7-T10 level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24134A Anterior cord syndrome at T11-T12 level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24134D Anterior cord syndrome at T11-T12 level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24134S Anterior cord syndrome at T11-T12 level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24139A Anterior cord syndrome at unspecified level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24139D Anterior cord syndrome at unspecified level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24139S Anterior cord syndrome at unspecified level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24141A Brown-Sequard syndrome at T1 level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24141D Brown-Sequard syndrome at T1 level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24141S Brown-Sequard syndrome at T1 level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24142A Brown-Sequard syndrome at T2-T6 level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24142D Brown-Sequard syndrome at T2-T6 level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24142S Brown-Sequard syndrome at T2-T6 level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24143A Brown-Sequard syndrome at T7-T10 level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24143D Brown-Sequard syndrome at T7-T10 level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24143S Brown-Sequard syndrome at T7-T10 level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24144A Brown-Sequard syndrome at T11-T12 level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24144D Brown-Sequard syndrome at T11-T12 level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24144S Brown-Sequard syndrome at T11-T12 level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24149A Brown-Sequard syndrome at unspecified level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24149D Brown-Sequard syndrome at unspecified level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24149S Brown-Sequard syndrome at unspecified level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24151A Other incomplete lesion at T1 level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24151D Other incomplete lesion at T1 level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24151S Other incomplete lesion at T1 level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24152A Other incomplete lesion at T2-T6 level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24152D Other incomplete lesion at T2-T6 level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24152S Other incomplete lesion at T2-T6 level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24153A Other incomplete lesion at T7-T10 level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24153D Other incomplete lesion at T7-T10 level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24153S Other incomplete lesion at T7-T10 level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24154A Other incomplete lesion at T11-T12 level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 186 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S24154D Other incomplete lesion at T11-T12 level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24154S Other incomplete lesion at T11-T12 level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S24159A Other incomplete lesion at unspecified level of thoracic spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S24159D Other incomplete lesion at unspecified level of thoracic spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S24159S Other incomplete lesion at unspecified level of thoracic spinal cord, sequela 72 72 72 Yes Yes Yes No
S32000A Wedge compression fracture of unspecified lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32000B Wedge compression fracture of unspecified lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32001A Stable burst fracture of unspecified lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32001B Stable burst fracture of unspecified lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32002A Unstable burst fracture of unspecified lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32002B Unstable burst fracture of unspecified lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32008A Other fracture of unspecified lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32008B Other fracture of unspecified lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32009A Unspecified fracture of unspecified lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32009B Unspecified fracture of unspecified lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32010A Wedge compression fracture of first lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32010B Wedge compression fracture of first lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32011A Stable burst fracture of first lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32011B Stable burst fracture of first lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32012A Unstable burst fracture of first lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32012B Unstable burst fracture of first lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32018A Other fracture of first lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32018B Other fracture of first lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32019A Unspecified fracture of first lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32019B Unspecified fracture of first lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32020A Wedge compression fracture of second lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32020B Wedge compression fracture of second lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32021A Stable burst fracture of second lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32021B Stable burst fracture of second lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32022A Unstable burst fracture of second lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32022B Unstable burst fracture of second lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32028A Other fracture of second lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32028B Other fracture of second lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32029A Unspecified fracture of second lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32029B Unspecified fracture of second lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32030A Wedge compression fracture of third lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32030B Wedge compression fracture of third lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32031A Stable burst fracture of third lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32031B Stable burst fracture of third lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32032A Unstable burst fracture of third lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32032B Unstable burst fracture of third lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32038A Other fracture of third lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32038B Other fracture of third lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32039A Unspecified fracture of third lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32039B Unspecified fracture of third lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32040A Wedge compression fracture of fourth lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32040B Wedge compression fracture of fourth lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32041A Stable burst fracture of fourth lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32041B Stable burst fracture of fourth lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32042A Unstable burst fracture of fourth lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32042B Unstable burst fracture of fourth lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 187 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S32048A Other fracture of fourth lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32048B Other fracture of fourth lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32049A Unspecified fracture of fourth lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32049B Unspecified fracture of fourth lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32050A Wedge compression fracture of fifth lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32050B Wedge compression fracture of fifth lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32051A Stable burst fracture of fifth lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32051B Stable burst fracture of fifth lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32052A Unstable burst fracture of fifth lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32052B Unstable burst fracture of fifth lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32058A Other fracture of fifth lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32058B Other fracture of fifth lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32059A Unspecified fracture of fifth lumbar vertebra, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32059B Unspecified fracture of fifth lumbar vertebra, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S3210XA Unspecified fracture of sacrum, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S3210XB Unspecified fracture of sacrum, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32110A Nondisplaced Zone I fracture of sacrum, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32110B Nondisplaced Zone I fracture of sacrum, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32111A Minimally displaced Zone I fracture of sacrum, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32111B Minimally displaced Zone I fracture of sacrum, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32112A Severely displaced Zone I fracture of sacrum, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32112B Severely displaced Zone I fracture of sacrum, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32119A Unspecified Zone I fracture of sacrum, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32119B Unspecified Zone I fracture of sacrum, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32120A Nondisplaced Zone II fracture of sacrum, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32120B Nondisplaced Zone II fracture of sacrum, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32121A Minimally displaced Zone II fracture of sacrum, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32121B Minimally displaced Zone II fracture of sacrum, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32122A Severely displaced Zone II fracture of sacrum, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32122B Severely displaced Zone II fracture of sacrum, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32129A Unspecified Zone II fracture of sacrum, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32129B Unspecified Zone II fracture of sacrum, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32130A Nondisplaced Zone III fracture of sacrum, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32130B Nondisplaced Zone III fracture of sacrum, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32131A Minimally displaced Zone III fracture of sacrum, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32131B Minimally displaced Zone III fracture of sacrum, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32132A Severely displaced Zone III fracture of sacrum, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32132B Severely displaced Zone III fracture of sacrum, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32139A Unspecified Zone III fracture of sacrum, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S32139B Unspecified Zone III fracture of sacrum, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S3214XA Type 1 fracture of sacrum, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S3214XB Type 1 fracture of sacrum, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S3215XA Type 2 fracture of sacrum, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S3215XB Type 2 fracture of sacrum, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S3216XA Type 3 fracture of sacrum, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S3216XB Type 3 fracture of sacrum, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S3217XA Type 4 fracture of sacrum, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S3217XB Type 4 fracture of sacrum, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S3219XA Other fracture of sacrum, initial encounter for closed fracture 169 169 169 Yes Yes Yes No
S3219XB Other fracture of sacrum, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S322XXA Fracture of coccyx, initial encounter for closed fracture 169 169 169 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 188 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S322XXB Fracture of coccyx, initial encounter for open fracture 169 169 169 Yes Yes Yes No
S32301A Unspecified fracture of right ilium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32301B Unspecified fracture of right ilium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32302A Unspecified fracture of left ilium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32302B Unspecified fracture of left ilium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32309A Unspecified fracture of unspecified ilium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32309B Unspecified fracture of unspecified ilium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32311A Displaced avulsion fracture of right ilium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32311B Displaced avulsion fracture of right ilium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32312A Displaced avulsion fracture of left ilium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32312B Displaced avulsion fracture of left ilium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32313A Displaced avulsion fracture of unspecified ilium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32313B Displaced avulsion fracture of unspecified ilium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32314A Nondisplaced avulsion fracture of right ilium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32314B Nondisplaced avulsion fracture of right ilium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32315A Nondisplaced avulsion fracture of left ilium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32315B Nondisplaced avulsion fracture of left ilium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32316A Nondisplaced avulsion fracture of unspecified ilium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32316B Nondisplaced avulsion fracture of unspecified ilium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32391A Other fracture of right ilium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32391B Other fracture of right ilium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32392A Other fracture of left ilium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32392B Other fracture of left ilium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32399A Other fracture of unspecified ilium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32399B Other fracture of unspecified ilium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32401A Unspecified fracture of right acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32401B Unspecified fracture of right acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32402A Unspecified fracture of left acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32402B Unspecified fracture of left acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32409A Unspecified fracture of unspecified acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32409B Unspecified fracture of unspecified acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32411A Displaced fracture of anterior wall of right acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32411B Displaced fracture of anterior wall of right acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32412A Displaced fracture of anterior wall of left acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32412B Displaced fracture of anterior wall of left acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32413A Displaced fracture of anterior wall of unspecified acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32413B Displaced fracture of anterior wall of unspecified acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32414A Nondisplaced fracture of anterior wall of right acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32414B Nondisplaced fracture of anterior wall of right acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32415A Nondisplaced fracture of anterior wall of left acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32415B Nondisplaced fracture of anterior wall of left acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32416A Nondisplaced fracture of anterior wall of unspecified acetabulum, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S32416B Nondisplaced fracture of anterior wall of unspecified acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32421A Displaced fracture of posterior wall of right acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32421B Displaced fracture of posterior wall of right acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32422A Displaced fracture of posterior wall of left acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32422B Displaced fracture of posterior wall of left acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32423A Displaced fracture of posterior wall of unspecified acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32423B Displaced fracture of posterior wall of unspecified acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32424A Nondisplaced fracture of posterior wall of right acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 189 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S32424B Nondisplaced fracture of posterior wall of right acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32425A Nondisplaced fracture of posterior wall of left acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32425B Nondisplaced fracture of posterior wall of left acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32426A Nondisplaced fracture of posterior wall of unspecified acetabulum, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S32426B Nondisplaced fracture of posterior wall of unspecified acetabulum, initial encounter for open 170 170 170 Yes Yes Yes No
fracture
S32431A Displaced fracture of anterior column [iliopubic] of right acetabulum, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S32431B Displaced fracture of anterior column [iliopubic] of right acetabulum, initial encounter for open 170 170 170 Yes Yes Yes No
fracture
S32432A Displaced fracture of anterior column [iliopubic] of left acetabulum, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S32432B Displaced fracture of anterior column [iliopubic] of left acetabulum, initial encounter for open 170 170 170 Yes Yes Yes No
fracture
S32433A Displaced fracture of anterior column [iliopubic] of unspecified acetabulum, initial encounter for 170 170 170 Yes Yes Yes No
closed fracture
S32433B Displaced fracture of anterior column [iliopubic] of unspecified acetabulum, initial encounter for 170 170 170 Yes Yes Yes No
open fracture
S32434A Nondisplaced fracture of anterior column [iliopubic] of right acetabulum, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S32434B Nondisplaced fracture of anterior column [iliopubic] of right acetabulum, initial encounter for open 170 170 170 Yes Yes Yes No
fracture
S32435A Nondisplaced fracture of anterior column [iliopubic] of left acetabulum, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S32435B Nondisplaced fracture of anterior column [iliopubic] of left acetabulum, initial encounter for open 170 170 170 Yes Yes Yes No
fracture
S32436A Nondisplaced fracture of anterior column [iliopubic] of unspecified acetabulum, initial encounter for 170 170 170 Yes Yes Yes No
closed fracture
S32436B Nondisplaced fracture of anterior column [iliopubic] of unspecified acetabulum, initial encounter for 170 170 170 Yes Yes Yes No
open fracture
S32441A Displaced fracture of posterior column [ilioischial] of right acetabulum, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S32441B Displaced fracture of posterior column [ilioischial] of right acetabulum, initial encounter for open 170 170 170 Yes Yes Yes No
fracture
S32442A Displaced fracture of posterior column [ilioischial] of left acetabulum, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S32442B Displaced fracture of posterior column [ilioischial] of left acetabulum, initial encounter for open 170 170 170 Yes Yes Yes No
fracture
S32443A Displaced fracture of posterior column [ilioischial] of unspecified acetabulum, initial encounter for 170 170 170 Yes Yes Yes No
closed fracture
S32443B Displaced fracture of posterior column [ilioischial] of unspecified acetabulum, initial encounter for 170 170 170 Yes Yes Yes No
open fracture
S32444A Nondisplaced fracture of posterior column [ilioischial] of right acetabulum, initial encounter for 170 170 170 Yes Yes Yes No
closed fracture
S32444B Nondisplaced fracture of posterior column [ilioischial] of right acetabulum, initial encounter for open 170 170 170 Yes Yes Yes No
fracture
S32445A Nondisplaced fracture of posterior column [ilioischial] of left acetabulum, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S32445B Nondisplaced fracture of posterior column [ilioischial] of left acetabulum, initial encounter for open 170 170 170 Yes Yes Yes No
fracture

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 190 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S32446A Nondisplaced fracture of posterior column [ilioischial] of unspecified acetabulum, initial encounter 170 170 170 Yes Yes Yes No
for closed fracture
S32446B Nondisplaced fracture of posterior column [ilioischial] of unspecified acetabulum, initial encounter 170 170 170 Yes Yes Yes No
for open fracture
S32451A Displaced transverse fracture of right acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32451B Displaced transverse fracture of right acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32452A Displaced transverse fracture of left acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32452B Displaced transverse fracture of left acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32453A Displaced transverse fracture of unspecified acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32453B Displaced transverse fracture of unspecified acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32454A Nondisplaced transverse fracture of right acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32454B Nondisplaced transverse fracture of right acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32455A Nondisplaced transverse fracture of left acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32455B Nondisplaced transverse fracture of left acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32456A Nondisplaced transverse fracture of unspecified acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32456B Nondisplaced transverse fracture of unspecified acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32461A Displaced associated transverse-posterior fracture of right acetabulum, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S32461B Displaced associated transverse-posterior fracture of right acetabulum, initial encounter for open 170 170 170 Yes Yes Yes No
fracture
S32462A Displaced associated transverse-posterior fracture of left acetabulum, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S32462B Displaced associated transverse-posterior fracture of left acetabulum, initial encounter for open 170 170 170 Yes Yes Yes No
fracture
S32463A Displaced associated transverse-posterior fracture of unspecified acetabulum, initial encounter for 170 170 170 Yes Yes Yes No
closed fracture
S32463B Displaced associated transverse-posterior fracture of unspecified acetabulum, initial encounter for 170 170 170 Yes Yes Yes No
open fracture
S32464A Nondisplaced associated transverse-posterior fracture of right acetabulum, initial encounter for 170 170 170 Yes Yes Yes No
closed fracture
S32464B Nondisplaced associated transverse-posterior fracture of right acetabulum, initial encounter for open 170 170 170 Yes Yes Yes No
fracture
S32465A Nondisplaced associated transverse-posterior fracture of left acetabulum, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S32465B Nondisplaced associated transverse-posterior fracture of left acetabulum, initial encounter for open 170 170 170 Yes Yes Yes No
fracture
S32466A Nondisplaced associated transverse-posterior fracture of unspecified acetabulum, initial encounter 170 170 170 Yes Yes Yes No
for closed fracture
S32466B Nondisplaced associated transverse-posterior fracture of unspecified acetabulum, initial encounter 170 170 170 Yes Yes Yes No
for open fracture
S32471A Displaced fracture of medial wall of right acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32471B Displaced fracture of medial wall of right acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32472A Displaced fracture of medial wall of left acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32472B Displaced fracture of medial wall of left acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32473A Displaced fracture of medial wall of unspecified acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32473B Displaced fracture of medial wall of unspecified acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32474A Nondisplaced fracture of medial wall of right acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32474B Nondisplaced fracture of medial wall of right acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32475A Nondisplaced fracture of medial wall of left acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32475B Nondisplaced fracture of medial wall of left acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32476A Nondisplaced fracture of medial wall of unspecified acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 191 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S32476B Nondisplaced fracture of medial wall of unspecified acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32481A Displaced dome fracture of right acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32481B Displaced dome fracture of right acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32482A Displaced dome fracture of left acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32482B Displaced dome fracture of left acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32483A Displaced dome fracture of unspecified acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32483B Displaced dome fracture of unspecified acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32484A Nondisplaced dome fracture of right acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32484B Nondisplaced dome fracture of right acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32485A Nondisplaced dome fracture of left acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32485B Nondisplaced dome fracture of left acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32486A Nondisplaced dome fracture of unspecified acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32486B Nondisplaced dome fracture of unspecified acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32491A Other specified fracture of right acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32491B Other specified fracture of right acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32492A Other specified fracture of left acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32492B Other specified fracture of left acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32499A Other specified fracture of unspecified acetabulum, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32499B Other specified fracture of unspecified acetabulum, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32501A Unspecified fracture of right pubis, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32501B Unspecified fracture of right pubis, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32502A Unspecified fracture of left pubis, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32502B Unspecified fracture of left pubis, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32509A Unspecified fracture of unspecified pubis, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32509B Unspecified fracture of unspecified pubis, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32511A Fracture of superior rim of right pubis, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32511B Fracture of superior rim of right pubis, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32512A Fracture of superior rim of left pubis, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32512B Fracture of superior rim of left pubis, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32519A Fracture of superior rim of unspecified pubis, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32519B Fracture of superior rim of unspecified pubis, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32591A Other specified fracture of right pubis, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32591B Other specified fracture of right pubis, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32592A Other specified fracture of left pubis, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32592B Other specified fracture of left pubis, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32599A Other specified fracture of unspecified pubis, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32599B Other specified fracture of unspecified pubis, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32601A Unspecified fracture of right ischium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32601B Unspecified fracture of right ischium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32602A Unspecified fracture of left ischium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32602B Unspecified fracture of left ischium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32609A Unspecified fracture of unspecified ischium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32609B Unspecified fracture of unspecified ischium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32611A Displaced avulsion fracture of right ischium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32611B Displaced avulsion fracture of right ischium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32612A Displaced avulsion fracture of left ischium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32612B Displaced avulsion fracture of left ischium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32613A Displaced avulsion fracture of unspecified ischium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32613B Displaced avulsion fracture of unspecified ischium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32614A Nondisplaced avulsion fracture of right ischium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32614B Nondisplaced avulsion fracture of right ischium, initial encounter for open fracture 170 170 170 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 192 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S32615A Nondisplaced avulsion fracture of left ischium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32615B Nondisplaced avulsion fracture of left ischium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32616A Nondisplaced avulsion fracture of unspecified ischium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32616B Nondisplaced avulsion fracture of unspecified ischium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32691A Other specified fracture of right ischium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32691B Other specified fracture of right ischium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32692A Other specified fracture of left ischium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32692B Other specified fracture of left ischium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32699A Other specified fracture of unspecified ischium, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32699B Other specified fracture of unspecified ischium, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32810A Multiple fractures of pelvis with stable disruption of pelvic ring, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S32810B Multiple fractures of pelvis with stable disruption of pelvic ring, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S32811A Multiple fractures of pelvis with unstable disruption of pelvic ring, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S32811B Multiple fractures of pelvis with unstable disruption of pelvic ring, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S3282XA Multiple fractures of pelvis without disruption of pelvic ring, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S3282XB Multiple fractures of pelvis without disruption of pelvic ring, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S3289XA Fracture of other parts of pelvis, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S3289XB Fracture of other parts of pelvis, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S329XXA Fracture of unspecified parts of lumbosacral spine and pelvis, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S329XXB Fracture of unspecified parts of lumbosacral spine and pelvis, initial encounter for open fracture 170 170 170 Yes Yes Yes No
S3401XA Concussion and edema of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S3401XD Concussion and edema of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S3401XS Concussion and edema of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No
S3402XA Concussion and edema of sacral spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S3402XD Concussion and edema of sacral spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S3402XS Concussion and edema of sacral spinal cord, sequela 72 72 72 Yes Yes Yes No
S34101A Unspecified injury to L1 level of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34101D Unspecified injury to L1 level of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34101S Unspecified injury to L1 level of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No
S34102A Unspecified injury to L2 level of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34102D Unspecified injury to L2 level of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34102S Unspecified injury to L2 level of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No
S34103A Unspecified injury to L3 level of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34103D Unspecified injury to L3 level of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34103S Unspecified injury to L3 level of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No
S34104A Unspecified injury to L4 level of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34104D Unspecified injury to L4 level of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34104S Unspecified injury to L4 level of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No
S34105A Unspecified injury to L5 level of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34105D Unspecified injury to L5 level of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34105S Unspecified injury to L5 level of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No
S34109A Unspecified injury to unspecified level of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34109D Unspecified injury to unspecified level of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34109S Unspecified injury to unspecified level of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No
S34111A Complete lesion of L1 level of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34111D Complete lesion of L1 level of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34111S Complete lesion of L1 level of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No
S34112A Complete lesion of L2 level of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34112D Complete lesion of L2 level of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34112S Complete lesion of L2 level of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 193 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S34113A Complete lesion of L3 level of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34113D Complete lesion of L3 level of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34113S Complete lesion of L3 level of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No
S34114A Complete lesion of L4 level of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34114D Complete lesion of L4 level of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34114S Complete lesion of L4 level of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No
S34115A Complete lesion of L5 level of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34115D Complete lesion of L5 level of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34115S Complete lesion of L5 level of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No
S34119A Complete lesion of unspecified level of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34119D Complete lesion of unspecified level of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34119S Complete lesion of unspecified level of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No
S34121A Incomplete lesion of L1 level of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34121D Incomplete lesion of L1 level of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34121S Incomplete lesion of L1 level of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No
S34122A Incomplete lesion of L2 level of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34122D Incomplete lesion of L2 level of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34122S Incomplete lesion of L2 level of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No
S34123A Incomplete lesion of L3 level of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34123D Incomplete lesion of L3 level of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34123S Incomplete lesion of L3 level of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No
S34124A Incomplete lesion of L4 level of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34124D Incomplete lesion of L4 level of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34124S Incomplete lesion of L4 level of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No
S34125A Incomplete lesion of L5 level of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34125D Incomplete lesion of L5 level of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34125S Incomplete lesion of L5 level of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No
S34129A Incomplete lesion of unspecified level of lumbar spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34129D Incomplete lesion of unspecified level of lumbar spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34129S Incomplete lesion of unspecified level of lumbar spinal cord, sequela 72 72 72 Yes Yes Yes No
S34131A Complete lesion of sacral spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34131D Complete lesion of sacral spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34131S Complete lesion of sacral spinal cord, sequela 72 72 72 Yes Yes Yes No
S34132A Incomplete lesion of sacral spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34132D Incomplete lesion of sacral spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34132S Incomplete lesion of sacral spinal cord, sequela 72 72 72 Yes Yes Yes No
S34139A Unspecified injury to sacral spinal cord, initial encounter 72 72 72 Yes Yes Yes No
S34139D Unspecified injury to sacral spinal cord, subsequent encounter 72 72 72 Yes Yes Yes No
S34139S Unspecified injury to sacral spinal cord, sequela 72 72 72 Yes Yes Yes No
S343XXA Injury of cauda equina, initial encounter 72 72 72 Yes Yes Yes No
S48011A Complete traumatic amputation at right shoulder joint, initial encounter 173 173 173 Yes Yes Yes No
S48011S Complete traumatic amputation at right shoulder joint, sequela 189 189 189 Yes Yes Yes No
S48012A Complete traumatic amputation at left shoulder joint, initial encounter 173 173 173 Yes Yes Yes No
S48012S Complete traumatic amputation at left shoulder joint, sequela 189 189 189 Yes Yes Yes No
S48019A Complete traumatic amputation at unspecified shoulder joint, initial encounter 173 173 173 Yes Yes Yes No
S48019S Complete traumatic amputation at unspecified shoulder joint, sequela 189 189 189 Yes Yes Yes No
S48021A Partial traumatic amputation at right shoulder joint, initial encounter 173 173 173 Yes Yes Yes No
S48021S Partial traumatic amputation at right shoulder joint, sequela 189 189 189 Yes Yes Yes No
S48022A Partial traumatic amputation at left shoulder joint, initial encounter 173 173 173 Yes Yes Yes No
S48022S Partial traumatic amputation at left shoulder joint, sequela 189 189 189 Yes Yes Yes No
S48029A Partial traumatic amputation at unspecified shoulder joint, initial encounter 173 173 173 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 194 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S48029S Partial traumatic amputation at unspecified shoulder joint, sequela 189 189 189 Yes Yes Yes No
S48111A Complete traumatic amputation at level between right shoulder and elbow, initial encounter 173 173 173 Yes Yes Yes No
S48111S Complete traumatic amputation at level between right shoulder and elbow, sequela 189 189 189 Yes Yes Yes No
S48112A Complete traumatic amputation at level between left shoulder and elbow, initial encounter 173 173 173 Yes Yes Yes No
S48112S Complete traumatic amputation at level between left shoulder and elbow, sequela 189 189 189 Yes Yes Yes No
S48119A Complete traumatic amputation at level between unspecified shoulder and elbow, initial encounter 173 173 173 Yes Yes Yes No
S48119S Complete traumatic amputation at level between unspecified shoulder and elbow, sequela 189 189 189 Yes Yes Yes No
S48121A Partial traumatic amputation at level between right shoulder and elbow, initial encounter 173 173 173 Yes Yes Yes No
S48121S Partial traumatic amputation at level between right shoulder and elbow, sequela 189 189 189 Yes Yes Yes No
S48122A Partial traumatic amputation at level between left shoulder and elbow, initial encounter 173 173 173 Yes Yes Yes No
S48122S Partial traumatic amputation at level between left shoulder and elbow, sequela 189 189 189 Yes Yes Yes No
S48129A Partial traumatic amputation at level between unspecified shoulder and elbow, initial encounter 173 173 173 Yes Yes Yes No
S48129S Partial traumatic amputation at level between unspecified shoulder and elbow, sequela 189 189 189 Yes Yes Yes No
S48911A Complete traumatic amputation of right shoulder and upper arm, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S48911S Complete traumatic amputation of right shoulder and upper arm, level unspecified, sequela 189 189 189 Yes Yes Yes No
S48912A Complete traumatic amputation of left shoulder and upper arm, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S48912S Complete traumatic amputation of left shoulder and upper arm, level unspecified, sequela 189 189 189 Yes Yes Yes No
S48919A Complete traumatic amputation of unspecified shoulder and upper arm, level unspecified, initial 173 173 173 Yes Yes Yes No
encounter
S48919S Complete traumatic amputation of unspecified shoulder and upper arm, level unspecified, sequela 189 189 189 Yes Yes Yes No
S48921A Partial traumatic amputation of right shoulder and upper arm, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S48921S Partial traumatic amputation of right shoulder and upper arm, level unspecified, sequela 189 189 189 Yes Yes Yes No
S48922A Partial traumatic amputation of left shoulder and upper arm, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S48922S Partial traumatic amputation of left shoulder and upper arm, level unspecified, sequela 189 189 189 Yes Yes Yes No
S48929A Partial traumatic amputation of unspecified shoulder and upper arm, level unspecified, initial 173 173 173 Yes Yes Yes No
encounter
S48929S Partial traumatic amputation of unspecified shoulder and upper arm, level unspecified, sequela 189 189 189 Yes Yes Yes No
S58011A Complete traumatic amputation at elbow level, right arm, initial encounter 173 173 173 Yes Yes Yes No
S58011S Complete traumatic amputation at elbow level, right arm, sequela 189 189 189 Yes Yes Yes No
S58012A Complete traumatic amputation at elbow level, left arm, initial encounter 173 173 173 Yes Yes Yes No
S58012S Complete traumatic amputation at elbow level, left arm, sequela 189 189 189 Yes Yes Yes No
S58019A Complete traumatic amputation at elbow level, unspecified arm, initial encounter 173 173 173 Yes Yes Yes No
S58019S Complete traumatic amputation at elbow level, unspecified arm, sequela 189 189 189 Yes Yes Yes No
S58021A Partial traumatic amputation at elbow level, right arm, initial encounter 173 173 173 Yes Yes Yes No
S58021S Partial traumatic amputation at elbow level, right arm, sequela 189 189 189 Yes Yes Yes No
S58022A Partial traumatic amputation at elbow level, left arm, initial encounter 173 173 173 Yes Yes Yes No
S58022S Partial traumatic amputation at elbow level, left arm, sequela 189 189 189 Yes Yes Yes No
S58029A Partial traumatic amputation at elbow level, unspecified arm, initial encounter 173 173 173 Yes Yes Yes No
S58029S Partial traumatic amputation at elbow level, unspecified arm, sequela 189 189 189 Yes Yes Yes No
S58111A Complete traumatic amputation at level between elbow and wrist, right arm, initial encounter 173 173 173 Yes Yes Yes No
S58111S Complete traumatic amputation at level between elbow and wrist, right arm, sequela 189 189 189 Yes Yes Yes No
S58112A Complete traumatic amputation at level between elbow and wrist, left arm, initial encounter 173 173 173 Yes Yes Yes No
S58112S Complete traumatic amputation at level between elbow and wrist, left arm, sequela 189 189 189 Yes Yes Yes No
S58119A Complete traumatic amputation at level between elbow and wrist, unspecified arm, initial encounter 173 173 173 Yes Yes Yes No
S58119S Complete traumatic amputation at level between elbow and wrist, unspecified arm, sequela 189 189 189 Yes Yes Yes No
S58121A Partial traumatic amputation at level between elbow and wrist, right arm, initial encounter 173 173 173 Yes Yes Yes No
S58121S Partial traumatic amputation at level between elbow and wrist, right arm, sequela 189 189 189 Yes Yes Yes No
S58122A Partial traumatic amputation at level between elbow and wrist, left arm, initial encounter 173 173 173 Yes Yes Yes No
S58122S Partial traumatic amputation at level between elbow and wrist, left arm, sequela 189 189 189 Yes Yes Yes No
S58129A Partial traumatic amputation at level between elbow and wrist, unspecified arm, initial encounter 173 173 173 Yes Yes Yes No
S58129S Partial traumatic amputation at level between elbow and wrist, unspecified arm, sequela 189 189 189 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 195 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S58911A Complete traumatic amputation of right forearm, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S58911S Complete traumatic amputation of right forearm, level unspecified, sequela 189 189 189 Yes Yes Yes No
S58912A Complete traumatic amputation of left forearm, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S58912S Complete traumatic amputation of left forearm, level unspecified, sequela 189 189 189 Yes Yes Yes No
S58919A Complete traumatic amputation of unspecified forearm, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S58919S Complete traumatic amputation of unspecified forearm, level unspecified, sequela 189 189 189 Yes Yes Yes No
S58921A Partial traumatic amputation of right forearm, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S58921S Partial traumatic amputation of right forearm, level unspecified, sequela 189 189 189 Yes Yes Yes No
S58922A Partial traumatic amputation of left forearm, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S58922S Partial traumatic amputation of left forearm, level unspecified, sequela 189 189 189 Yes Yes Yes No
S58929A Partial traumatic amputation of unspecified forearm, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S58929S Partial traumatic amputation of unspecified forearm, level unspecified, sequela 189 189 189 Yes Yes Yes No
S68011S Complete traumatic metacarpophalangeal amputation of right thumb, sequela 189 189 189 Yes Yes Yes No
S68012S Complete traumatic metacarpophalangeal amputation of left thumb, sequela 189 189 189 Yes Yes Yes No
S68019S Complete traumatic metacarpophalangeal amputation of unspecified thumb, sequela 189 189 189 Yes Yes Yes No
S68021S Partial traumatic metacarpophalangeal amputation of right thumb, sequela 189 189 189 Yes Yes Yes No
S68022S Partial traumatic metacarpophalangeal amputation of left thumb, sequela 189 189 189 Yes Yes Yes No
S68029S Partial traumatic metacarpophalangeal amputation of unspecified thumb, sequela 189 189 189 Yes Yes Yes No
S68110S Complete traumatic metacarpophalangeal amputation of right index finger, sequela 189 189 189 Yes Yes Yes No
S68111S Complete traumatic metacarpophalangeal amputation of left index finger, sequela 189 189 189 Yes Yes Yes No
S68112S Complete traumatic metacarpophalangeal amputation of right middle finger, sequela 189 189 189 Yes Yes Yes No
S68113S Complete traumatic metacarpophalangeal amputation of left middle finger, sequela 189 189 189 Yes Yes Yes No
S68114S Complete traumatic metacarpophalangeal amputation of right ring finger, sequela 189 189 189 Yes Yes Yes No
S68115S Complete traumatic metacarpophalangeal amputation of left ring finger, sequela 189 189 189 Yes Yes Yes No
S68116S Complete traumatic metacarpophalangeal amputation of right little finger, sequela 189 189 189 Yes Yes Yes No
S68117S Complete traumatic metacarpophalangeal amputation of left little finger, sequela 189 189 189 Yes Yes Yes No
S68118S Complete traumatic metacarpophalangeal amputation of other finger, sequela 189 189 189 Yes Yes Yes No
S68119S Complete traumatic metacarpophalangeal amputation of unspecified finger, sequela 189 189 189 Yes Yes Yes No
S68120S Partial traumatic metacarpophalangeal amputation of right index finger, sequela 189 189 189 Yes Yes Yes No
S68121S Partial traumatic metacarpophalangeal amputation of left index finger, sequela 189 189 189 Yes Yes Yes No
S68122S Partial traumatic metacarpophalangeal amputation of right middle finger, sequela 189 189 189 Yes Yes Yes No
S68123S Partial traumatic metacarpophalangeal amputation of left middle finger, sequela 189 189 189 Yes Yes Yes No
S68124S Partial traumatic metacarpophalangeal amputation of right ring finger, sequela 189 189 189 Yes Yes Yes No
S68125S Partial traumatic metacarpophalangeal amputation of left ring finger, sequela 189 189 189 Yes Yes Yes No
S68126S Partial traumatic metacarpophalangeal amputation of right little finger, sequela 189 189 189 Yes Yes Yes No
S68127S Partial traumatic metacarpophalangeal amputation of left little finger, sequela 189 189 189 Yes Yes Yes No
S68128S Partial traumatic metacarpophalangeal amputation of other finger, sequela 189 189 189 Yes Yes Yes No
S68129S Partial traumatic metacarpophalangeal amputation of unspecified finger, sequela 189 189 189 Yes Yes Yes No
S68411A Complete traumatic amputation of right hand at wrist level, initial encounter 173 173 173 Yes Yes Yes No
S68411S Complete traumatic amputation of right hand at wrist level, sequela 189 189 189 Yes Yes Yes No
S68412A Complete traumatic amputation of left hand at wrist level, initial encounter 173 173 173 Yes Yes Yes No
S68412S Complete traumatic amputation of left hand at wrist level, sequela 189 189 189 Yes Yes Yes No
S68419A Complete traumatic amputation of unspecified hand at wrist level, initial encounter 173 173 173 Yes Yes Yes No
S68419S Complete traumatic amputation of unspecified hand at wrist level, sequela 189 189 189 Yes Yes Yes No
S68421A Partial traumatic amputation of right hand at wrist level, initial encounter 173 173 173 Yes Yes Yes No
S68421S Partial traumatic amputation of right hand at wrist level, sequela 189 189 189 Yes Yes Yes No
S68422A Partial traumatic amputation of left hand at wrist level, initial encounter 173 173 173 Yes Yes Yes No
S68422S Partial traumatic amputation of left hand at wrist level, sequela 189 189 189 Yes Yes Yes No
S68429A Partial traumatic amputation of unspecified hand at wrist level, initial encounter 173 173 173 Yes Yes Yes No
S68429S Partial traumatic amputation of unspecified hand at wrist level, sequela 189 189 189 Yes Yes Yes No
S68511S Complete traumatic transphalangeal amputation of right thumb, sequela 189 189 189 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 196 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S68512S Complete traumatic transphalangeal amputation of left thumb, sequela 189 189 189 Yes Yes Yes No
S68519S Complete traumatic transphalangeal amputation of unspecified thumb, sequela 189 189 189 Yes Yes Yes No
S68521S Partial traumatic transphalangeal amputation of right thumb, sequela 189 189 189 Yes Yes Yes No
S68522S Partial traumatic transphalangeal amputation of left thumb, sequela 189 189 189 Yes Yes Yes No
S68529S Partial traumatic transphalangeal amputation of unspecified thumb, sequela 189 189 189 Yes Yes Yes No
S68610S Complete traumatic transphalangeal amputation of right index finger, sequela 189 189 189 Yes Yes Yes No
S68611S Complete traumatic transphalangeal amputation of left index finger, sequela 189 189 189 Yes Yes Yes No
S68612S Complete traumatic transphalangeal amputation of right middle finger, sequela 189 189 189 Yes Yes Yes No
S68613S Complete traumatic transphalangeal amputation of left middle finger, sequela 189 189 189 Yes Yes Yes No
S68614S Complete traumatic transphalangeal amputation of right ring finger, sequela 189 189 189 Yes Yes Yes No
S68615S Complete traumatic transphalangeal amputation of left ring finger, sequela 189 189 189 Yes Yes Yes No
S68616S Complete traumatic transphalangeal amputation of right little finger, sequela 189 189 189 Yes Yes Yes No
S68617S Complete traumatic transphalangeal amputation of left little finger, sequela 189 189 189 Yes Yes Yes No
S68618S Complete traumatic transphalangeal amputation of other finger, sequela 189 189 189 Yes Yes Yes No
S68619S Complete traumatic transphalangeal amputation of unspecified finger, sequela 189 189 189 Yes Yes Yes No
S68620S Partial traumatic transphalangeal amputation of right index finger, sequela 189 189 189 Yes Yes Yes No
S68621S Partial traumatic transphalangeal amputation of left index finger, sequela 189 189 189 Yes Yes Yes No
S68622S Partial traumatic transphalangeal amputation of right middle finger, sequela 189 189 189 Yes Yes Yes No
S68623S Partial traumatic transphalangeal amputation of left middle finger, sequela 189 189 189 Yes Yes Yes No
S68624S Partial traumatic transphalangeal amputation of right ring finger, sequela 189 189 189 Yes Yes Yes No
S68625S Partial traumatic transphalangeal amputation of left ring finger, sequela 189 189 189 Yes Yes Yes No
S68626S Partial traumatic transphalangeal amputation of right little finger, sequela 189 189 189 Yes Yes Yes No
S68627S Partial traumatic transphalangeal amputation of left little finger, sequela 189 189 189 Yes Yes Yes No
S68628S Partial traumatic transphalangeal amputation of other finger, sequela 189 189 189 Yes Yes Yes No
S68629S Partial traumatic transphalangeal amputation of unspecified finger, sequela 189 189 189 Yes Yes Yes No
S68711A Complete traumatic transmetacarpal amputation of right hand, initial encounter 173 173 173 Yes Yes Yes No
S68711S Complete traumatic transmetacarpal amputation of right hand, sequela 189 189 189 Yes Yes Yes No
S68712A Complete traumatic transmetacarpal amputation of left hand, initial encounter 173 173 173 Yes Yes Yes No
S68712S Complete traumatic transmetacarpal amputation of left hand, sequela 189 189 189 Yes Yes Yes No
S68719A Complete traumatic transmetacarpal amputation of unspecified hand, initial encounter 173 173 173 Yes Yes Yes No
S68719S Complete traumatic transmetacarpal amputation of unspecified hand, sequela 189 189 189 Yes Yes Yes No
S68721A Partial traumatic transmetacarpal amputation of right hand, initial encounter 173 173 173 Yes Yes Yes No
S68721S Partial traumatic transmetacarpal amputation of right hand, sequela 189 189 189 Yes Yes Yes No
S68722A Partial traumatic transmetacarpal amputation of left hand, initial encounter 173 173 173 Yes Yes Yes No
S68722S Partial traumatic transmetacarpal amputation of left hand, sequela 189 189 189 Yes Yes Yes No
S68729A Partial traumatic transmetacarpal amputation of unspecified hand, initial encounter 173 173 173 Yes Yes Yes No
S68729S Partial traumatic transmetacarpal amputation of unspecified hand, sequela 189 189 189 Yes Yes Yes No
S72001A Fracture of unspecified part of neck of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72001B Fracture of unspecified part of neck of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72001C Fracture of unspecified part of neck of right femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S72002A Fracture of unspecified part of neck of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72002B Fracture of unspecified part of neck of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72002C Fracture of unspecified part of neck of left femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72009A Fracture of unspecified part of neck of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72009B Fracture of unspecified part of neck of unspecified femur, initial encounter for open fracture type I or 170 170 170 Yes Yes Yes No
II
S72009C Fracture of unspecified part of neck of unspecified femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
IIIA, IIIB, or IIIC
S72011A Unspecified intracapsular fracture of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 197 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S72011B Unspecified intracapsular fracture of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72011C Unspecified intracapsular fracture of right femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72012A Unspecified intracapsular fracture of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72012B Unspecified intracapsular fracture of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72012C Unspecified intracapsular fracture of left femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72019A Unspecified intracapsular fracture of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72019B Unspecified intracapsular fracture of unspecified femur, initial encounter for open fracture type I or 170 170 170 Yes Yes Yes No
II
S72019C Unspecified intracapsular fracture of unspecified femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72021A Displaced fracture of epiphysis (separation) (upper) of right femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S72021B Displaced fracture of epiphysis (separation) (upper) of right femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type I or II
S72021C Displaced fracture of epiphysis (separation) (upper) of right femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type IIIA, IIIB, or IIIC
S72022A Displaced fracture of epiphysis (separation) (upper) of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No

S72022B Displaced fracture of epiphysis (separation) (upper) of left femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type I or II
S72022C Displaced fracture of epiphysis (separation) (upper) of left femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type IIIA, IIIB, or IIIC
S72023A Displaced fracture of epiphysis (separation) (upper) of unspecified femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S72023B Displaced fracture of epiphysis (separation) (upper) of unspecified femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type I or II
S72023C Displaced fracture of epiphysis (separation) (upper) of unspecified femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type IIIA, IIIB, or IIIC
S72024A Nondisplaced fracture of epiphysis (separation) (upper) of right femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S72024B Nondisplaced fracture of epiphysis (separation) (upper) of right femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type I or II
S72024C Nondisplaced fracture of epiphysis (separation) (upper) of right femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type IIIA, IIIB, or IIIC
S72025A Nondisplaced fracture of epiphysis (separation) (upper) of left femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S72025B Nondisplaced fracture of epiphysis (separation) (upper) of left femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type I or II
S72025C Nondisplaced fracture of epiphysis (separation) (upper) of left femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type IIIA, IIIB, or IIIC
S72026A Nondisplaced fracture of epiphysis (separation) (upper) of unspecified femur, initial encounter for 170 170 170 Yes Yes Yes No
closed fracture
S72026B Nondisplaced fracture of epiphysis (separation) (upper) of unspecified femur, initial encounter for 170 170 170 Yes Yes Yes No
open fracture type I or II
S72026C Nondisplaced fracture of epiphysis (separation) (upper) of unspecified femur, initial encounter for 170 170 170 Yes Yes Yes No
open fracture type IIIA, IIIB, or IIIC
S72031A Displaced midcervical fracture of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72031B Displaced midcervical fracture of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72031C Displaced midcervical fracture of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 198 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S72032A Displaced midcervical fracture of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72032B Displaced midcervical fracture of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72032C Displaced midcervical fracture of left femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No
S72033A Displaced midcervical fracture of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72033B Displaced midcervical fracture of unspecified femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72033C Displaced midcervical fracture of unspecified femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S72034A Nondisplaced midcervical fracture of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72034B Nondisplaced midcervical fracture of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72034C Nondisplaced midcervical fracture of right femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72035A Nondisplaced midcervical fracture of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72035B Nondisplaced midcervical fracture of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72035C Nondisplaced midcervical fracture of left femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72036A Nondisplaced midcervical fracture of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72036B Nondisplaced midcervical fracture of unspecified femur, initial encounter for open fracture type I or 170 170 170 Yes Yes Yes No
II
S72036C Nondisplaced midcervical fracture of unspecified femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72041A Displaced fracture of base of neck of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72041B Displaced fracture of base of neck of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72041C Displaced fracture of base of neck of right femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72042A Displaced fracture of base of neck of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72042B Displaced fracture of base of neck of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72042C Displaced fracture of base of neck of left femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72043A Displaced fracture of base of neck of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72043B Displaced fracture of base of neck of unspecified femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No

S72043C Displaced fracture of base of neck of unspecified femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72044A Nondisplaced fracture of base of neck of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72044B Nondisplaced fracture of base of neck of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72044C Nondisplaced fracture of base of neck of right femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72045A Nondisplaced fracture of base of neck of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72045B Nondisplaced fracture of base of neck of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72045C Nondisplaced fracture of base of neck of left femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S72046A Nondisplaced fracture of base of neck of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72046B Nondisplaced fracture of base of neck of unspecified femur, initial encounter for open fracture type I 170 170 170 Yes Yes Yes No
or II
S72046C Nondisplaced fracture of base of neck of unspecified femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
IIIA, IIIB, or IIIC
S72051A Unspecified fracture of head of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72051B Unspecified fracture of head of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72051C Unspecified fracture of head of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No
S72052A Unspecified fracture of head of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72052B Unspecified fracture of head of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 199 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S72052C Unspecified fracture of head of left femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No
S72059A Unspecified fracture of head of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72059B Unspecified fracture of head of unspecified femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72059C Unspecified fracture of head of unspecified femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S72061A Displaced articular fracture of head of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72061B Displaced articular fracture of head of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72061C Displaced articular fracture of head of right femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S72062A Displaced articular fracture of head of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72062B Displaced articular fracture of head of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72062C Displaced articular fracture of head of left femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72063A Displaced articular fracture of head of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72063B Displaced articular fracture of head of unspecified femur, initial encounter for open fracture type I or 170 170 170 Yes Yes Yes No
II
S72063C Displaced articular fracture of head of unspecified femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
IIIA, IIIB, or IIIC
S72064A Nondisplaced articular fracture of head of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72064B Nondisplaced articular fracture of head of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72064C Nondisplaced articular fracture of head of right femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72065A Nondisplaced articular fracture of head of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72065B Nondisplaced articular fracture of head of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72065C Nondisplaced articular fracture of head of left femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72066A Nondisplaced articular fracture of head of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72066B Nondisplaced articular fracture of head of unspecified femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
I or II
S72066C Nondisplaced articular fracture of head of unspecified femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
IIIA, IIIB, or IIIC
S72091A Other fracture of head and neck of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72091B Other fracture of head and neck of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72091C Other fracture of head and neck of right femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72092A Other fracture of head and neck of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72092B Other fracture of head and neck of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72092C Other fracture of head and neck of left femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No

S72099A Other fracture of head and neck of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72099B Other fracture of head and neck of unspecified femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72099C Other fracture of head and neck of unspecified femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72101A Unspecified trochanteric fracture of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72101B Unspecified trochanteric fracture of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72101C Unspecified trochanteric fracture of right femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72102A Unspecified trochanteric fracture of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72102B Unspecified trochanteric fracture of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72102C Unspecified trochanteric fracture of left femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 200 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S72109A Unspecified trochanteric fracture of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72109B Unspecified trochanteric fracture of unspecified femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72109C Unspecified trochanteric fracture of unspecified femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72111A Displaced fracture of greater trochanter of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72111B Displaced fracture of greater trochanter of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72111C Displaced fracture of greater trochanter of right femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72112A Displaced fracture of greater trochanter of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72112B Displaced fracture of greater trochanter of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72112C Displaced fracture of greater trochanter of left femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72113A Displaced fracture of greater trochanter of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72113B Displaced fracture of greater trochanter of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type I or II
S72113C Displaced fracture of greater trochanter of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type IIIA, IIIB, or IIIC
S72114A Nondisplaced fracture of greater trochanter of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72114B Nondisplaced fracture of greater trochanter of right femur, initial encounter for open fracture type I 170 170 170 Yes Yes Yes No
or II
S72114C Nondisplaced fracture of greater trochanter of right femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
IIIA, IIIB, or IIIC
S72115A Nondisplaced fracture of greater trochanter of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72115B Nondisplaced fracture of greater trochanter of left femur, initial encounter for open fracture type I or 170 170 170 Yes Yes Yes No
II
S72115C Nondisplaced fracture of greater trochanter of left femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
IIIA, IIIB, or IIIC
S72116A Nondisplaced fracture of greater trochanter of unspecified femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S72116B Nondisplaced fracture of greater trochanter of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type I or II
S72116C Nondisplaced fracture of greater trochanter of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type IIIA, IIIB, or IIIC
S72121A Displaced fracture of lesser trochanter of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72121B Displaced fracture of lesser trochanter of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72121C Displaced fracture of lesser trochanter of right femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72122A Displaced fracture of lesser trochanter of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72122B Displaced fracture of lesser trochanter of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72122C Displaced fracture of lesser trochanter of left femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S72123A Displaced fracture of lesser trochanter of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72123B Displaced fracture of lesser trochanter of unspecified femur, initial encounter for open fracture type I 170 170 170 Yes Yes Yes No
or II
S72123C Displaced fracture of lesser trochanter of unspecified femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
IIIA, IIIB, or IIIC
S72124A Nondisplaced fracture of lesser trochanter of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72124B Nondisplaced fracture of lesser trochanter of right femur, initial encounter for open fracture type I or 170 170 170 Yes Yes Yes No
II
S72124C Nondisplaced fracture of lesser trochanter of right femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
IIIA, IIIB, or IIIC

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 201 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S72125A Nondisplaced fracture of lesser trochanter of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72125B Nondisplaced fracture of lesser trochanter of left femur, initial encounter for open fracture type I or 170 170 170 Yes Yes Yes No
II
S72125C Nondisplaced fracture of lesser trochanter of left femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72126A Nondisplaced fracture of lesser trochanter of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72126B Nondisplaced fracture of lesser trochanter of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type I or II
S72126C Nondisplaced fracture of lesser trochanter of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type IIIA, IIIB, or IIIC
S72131A Displaced apophyseal fracture of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72131B Displaced apophyseal fracture of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72131C Displaced apophyseal fracture of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No
S72132A Displaced apophyseal fracture of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72132B Displaced apophyseal fracture of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72132C Displaced apophyseal fracture of left femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No
S72133A Displaced apophyseal fracture of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72133B Displaced apophyseal fracture of unspecified femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72133C Displaced apophyseal fracture of unspecified femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S72134A Nondisplaced apophyseal fracture of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72134B Nondisplaced apophyseal fracture of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72134C Nondisplaced apophyseal fracture of right femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72135A Nondisplaced apophyseal fracture of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72135B Nondisplaced apophyseal fracture of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72135C Nondisplaced apophyseal fracture of left femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72136A Nondisplaced apophyseal fracture of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72136B Nondisplaced apophyseal fracture of unspecified femur, initial encounter for open fracture type I or 170 170 170 Yes Yes Yes No
II
S72136C Nondisplaced apophyseal fracture of unspecified femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72141A Displaced intertrochanteric fracture of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72141B Displaced intertrochanteric fracture of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72141C Displaced intertrochanteric fracture of right femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S72142A Displaced intertrochanteric fracture of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72142B Displaced intertrochanteric fracture of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72142C Displaced intertrochanteric fracture of left femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72143A Displaced intertrochanteric fracture of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72143B Displaced intertrochanteric fracture of unspecified femur, initial encounter for open fracture type I 170 170 170 Yes Yes Yes No
or II
S72143C Displaced intertrochanteric fracture of unspecified femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
IIIA, IIIB, or IIIC
S72144A Nondisplaced intertrochanteric fracture of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72144B Nondisplaced intertrochanteric fracture of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72144C Nondisplaced intertrochanteric fracture of right femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72145A Nondisplaced intertrochanteric fracture of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 202 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S72145B Nondisplaced intertrochanteric fracture of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72145C Nondisplaced intertrochanteric fracture of left femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72146A Nondisplaced intertrochanteric fracture of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72146B Nondisplaced intertrochanteric fracture of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type I or II
S72146C Nondisplaced intertrochanteric fracture of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type IIIA, IIIB, or IIIC
S7221XA Displaced subtrochanteric fracture of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S7221XB Displaced subtrochanteric fracture of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S7221XC Displaced subtrochanteric fracture of right femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S7222XA Displaced subtrochanteric fracture of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S7222XB Displaced subtrochanteric fracture of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S7222XC Displaced subtrochanteric fracture of left femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S7223XA Displaced subtrochanteric fracture of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S7223XB Displaced subtrochanteric fracture of unspecified femur, initial encounter for open fracture type I or 170 170 170 Yes Yes Yes No
II
S7223XC Displaced subtrochanteric fracture of unspecified femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S7224XA Nondisplaced subtrochanteric fracture of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S7224XB Nondisplaced subtrochanteric fracture of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S7224XC Nondisplaced subtrochanteric fracture of right femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S7225XA Nondisplaced subtrochanteric fracture of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S7225XB Nondisplaced subtrochanteric fracture of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S7225XC Nondisplaced subtrochanteric fracture of left femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S7226XA Nondisplaced subtrochanteric fracture of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S7226XB Nondisplaced subtrochanteric fracture of unspecified femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
I or II
S7226XC Nondisplaced subtrochanteric fracture of unspecified femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
IIIA, IIIB, or IIIC
S72301A Unspecified fracture of shaft of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72301B Unspecified fracture of shaft of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72301C Unspecified fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No
S72302A Unspecified fracture of shaft of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72302B Unspecified fracture of shaft of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72302C Unspecified fracture of shaft of left femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No
S72309A Unspecified fracture of shaft of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72309B Unspecified fracture of shaft of unspecified femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72309C Unspecified fracture of shaft of unspecified femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S72321A Displaced transverse fracture of shaft of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72321B Displaced transverse fracture of shaft of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72321C Displaced transverse fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S72322A Displaced transverse fracture of shaft of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72322B Displaced transverse fracture of shaft of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 203 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S72322C Displaced transverse fracture of shaft of left femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S72323A Displaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72323B Displaced transverse fracture of shaft of unspecified femur, initial encounter for open fracture type I 170 170 170 Yes Yes Yes No
or II
S72323C Displaced transverse fracture of shaft of unspecified femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
IIIA, IIIB, or IIIC
S72324A Nondisplaced transverse fracture of shaft of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72324B Nondisplaced transverse fracture of shaft of right femur, initial encounter for open fracture type I or 170 170 170 Yes Yes Yes No
II
S72324C Nondisplaced transverse fracture of shaft of right femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72325A Nondisplaced transverse fracture of shaft of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72325B Nondisplaced transverse fracture of shaft of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72325C Nondisplaced transverse fracture of shaft of left femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72326A Nondisplaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72326B Nondisplaced transverse fracture of shaft of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type I or II
S72326C Nondisplaced transverse fracture of shaft of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type IIIA, IIIB, or IIIC
S72331A Displaced oblique fracture of shaft of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72331B Displaced oblique fracture of shaft of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72331C Displaced oblique fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72332A Displaced oblique fracture of shaft of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72332B Displaced oblique fracture of shaft of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72332C Displaced oblique fracture of shaft of left femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72333A Displaced oblique fracture of shaft of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72333B Displaced oblique fracture of shaft of unspecified femur, initial encounter for open fracture type I or 170 170 170 Yes Yes Yes No
II
S72333C Displaced oblique fracture of shaft of unspecified femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72334A Nondisplaced oblique fracture of shaft of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72334B Nondisplaced oblique fracture of shaft of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72334C Nondisplaced oblique fracture of shaft of right femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72335A Nondisplaced oblique fracture of shaft of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72335B Nondisplaced oblique fracture of shaft of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72335C Nondisplaced oblique fracture of shaft of left femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S72336A Nondisplaced oblique fracture of shaft of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72336B Nondisplaced oblique fracture of shaft of unspecified femur, initial encounter for open fracture type I 170 170 170 Yes Yes Yes No
or II
S72336C Nondisplaced oblique fracture of shaft of unspecified femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
IIIA, IIIB, or IIIC
S72341A Displaced spiral fracture of shaft of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72341B Displaced spiral fracture of shaft of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72341C Displaced spiral fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 204 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S72342A Displaced spiral fracture of shaft of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72342B Displaced spiral fracture of shaft of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72342C Displaced spiral fracture of shaft of left femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No

S72343A Displaced spiral fracture of shaft of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72343B Displaced spiral fracture of shaft of unspecified femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72343C Displaced spiral fracture of shaft of unspecified femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72344A Nondisplaced spiral fracture of shaft of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72344B Nondisplaced spiral fracture of shaft of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72344C Nondisplaced spiral fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S72345A Nondisplaced spiral fracture of shaft of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72345B Nondisplaced spiral fracture of shaft of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72345C Nondisplaced spiral fracture of shaft of left femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72346A Nondisplaced spiral fracture of shaft of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72346B Nondisplaced spiral fracture of shaft of unspecified femur, initial encounter for open fracture type I 170 170 170 Yes Yes Yes No
or II
S72346C Nondisplaced spiral fracture of shaft of unspecified femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
IIIA, IIIB, or IIIC
S72351A Displaced comminuted fracture of shaft of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72351B Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72351C Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72352A Displaced comminuted fracture of shaft of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72352B Displaced comminuted fracture of shaft of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72352C Displaced comminuted fracture of shaft of left femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72353A Displaced comminuted fracture of shaft of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72353B Displaced comminuted fracture of shaft of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type I or II
S72353C Displaced comminuted fracture of shaft of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type IIIA, IIIB, or IIIC
S72354A Nondisplaced comminuted fracture of shaft of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72354B Nondisplaced comminuted fracture of shaft of right femur, initial encounter for open fracture type I 170 170 170 Yes Yes Yes No
or II
S72354C Nondisplaced comminuted fracture of shaft of right femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
IIIA, IIIB, or IIIC
S72355A Nondisplaced comminuted fracture of shaft of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72355B Nondisplaced comminuted fracture of shaft of left femur, initial encounter for open fracture type I or 170 170 170 Yes Yes Yes No
II
S72355C Nondisplaced comminuted fracture of shaft of left femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
IIIA, IIIB, or IIIC
S72356A Nondisplaced comminuted fracture of shaft of unspecified femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S72356B Nondisplaced comminuted fracture of shaft of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type I or II
S72356C Nondisplaced comminuted fracture of shaft of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type IIIA, IIIB, or IIIC
S72361A Displaced segmental fracture of shaft of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 205 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S72361B Displaced segmental fracture of shaft of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72361C Displaced segmental fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S72362A Displaced segmental fracture of shaft of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72362B Displaced segmental fracture of shaft of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72362C Displaced segmental fracture of shaft of left femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S72363A Displaced segmental fracture of shaft of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72363B Displaced segmental fracture of shaft of unspecified femur, initial encounter for open fracture type I 170 170 170 Yes Yes Yes No
or II
S72363C Displaced segmental fracture of shaft of unspecified femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
IIIA, IIIB, or IIIC
S72364A Nondisplaced segmental fracture of shaft of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72364B Nondisplaced segmental fracture of shaft of right femur, initial encounter for open fracture type I or 170 170 170 Yes Yes Yes No
II
S72364C Nondisplaced segmental fracture of shaft of right femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72365A Nondisplaced segmental fracture of shaft of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72365B Nondisplaced segmental fracture of shaft of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72365C Nondisplaced segmental fracture of shaft of left femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72366A Nondisplaced segmental fracture of shaft of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72366B Nondisplaced segmental fracture of shaft of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type I or II
S72366C Nondisplaced segmental fracture of shaft of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type IIIA, IIIB, or IIIC
S72391A Other fracture of shaft of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72391B Other fracture of shaft of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72391C Other fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No
S72392A Other fracture of shaft of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72392B Other fracture of shaft of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72392C Other fracture of shaft of left femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No
S72399A Other fracture of shaft of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72399B Other fracture of shaft of unspecified femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72399C Other fracture of shaft of unspecified femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No
S72401A Unspecified fracture of lower end of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72401B Unspecified fracture of lower end of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72401C Unspecified fracture of lower end of right femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72402A Unspecified fracture of lower end of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72402B Unspecified fracture of lower end of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72402C Unspecified fracture of lower end of left femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72409A Unspecified fracture of lower end of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72409B Unspecified fracture of lower end of unspecified femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No

S72409C Unspecified fracture of lower end of unspecified femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72411A Displaced unspecified condyle fracture of lower end of right femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 206 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S72411B Displaced unspecified condyle fracture of lower end of right femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type I or II
S72411C Displaced unspecified condyle fracture of lower end of right femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type IIIA, IIIB, or IIIC
S72412A Displaced unspecified condyle fracture of lower end of left femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S72412B Displaced unspecified condyle fracture of lower end of left femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type I or II
S72412C Displaced unspecified condyle fracture of lower end of left femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type IIIA, IIIB, or IIIC
S72413A Displaced unspecified condyle fracture of lower end of unspecified femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S72413B Displaced unspecified condyle fracture of lower end of unspecified femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type I or II
S72413C Displaced unspecified condyle fracture of lower end of unspecified femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type IIIA, IIIB, or IIIC
S72414A Nondisplaced unspecified condyle fracture of lower end of right femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S72414B Nondisplaced unspecified condyle fracture of lower end of right femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type I or II
S72414C Nondisplaced unspecified condyle fracture of lower end of right femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type IIIA, IIIB, or IIIC
S72415A Nondisplaced unspecified condyle fracture of lower end of left femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S72415B Nondisplaced unspecified condyle fracture of lower end of left femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type I or II
S72415C Nondisplaced unspecified condyle fracture of lower end of left femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type IIIA, IIIB, or IIIC
S72416A Nondisplaced unspecified condyle fracture of lower end of unspecified femur, initial encounter for 170 170 170 Yes Yes Yes No
closed fracture
S72416B Nondisplaced unspecified condyle fracture of lower end of unspecified femur, initial encounter for 170 170 170 Yes Yes Yes No
open fracture type I or II
S72416C Nondisplaced unspecified condyle fracture of lower end of unspecified femur, initial encounter for 170 170 170 Yes Yes Yes No
open fracture type IIIA, IIIB, or IIIC
S72421A Displaced fracture of lateral condyle of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72421B Displaced fracture of lateral condyle of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72421C Displaced fracture of lateral condyle of right femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S72422A Displaced fracture of lateral condyle of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72422B Displaced fracture of lateral condyle of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72422C Displaced fracture of lateral condyle of left femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S72423A Displaced fracture of lateral condyle of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72423B Displaced fracture of lateral condyle of unspecified femur, initial encounter for open fracture type I 170 170 170 Yes Yes Yes No
or II
S72423C Displaced fracture of lateral condyle of unspecified femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
IIIA, IIIB, or IIIC
S72424A Nondisplaced fracture of lateral condyle of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72424B Nondisplaced fracture of lateral condyle of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72424C Nondisplaced fracture of lateral condyle of right femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 207 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S72425A Nondisplaced fracture of lateral condyle of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72425B Nondisplaced fracture of lateral condyle of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72425C Nondisplaced fracture of lateral condyle of left femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72426A Nondisplaced fracture of lateral condyle of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72426B Nondisplaced fracture of lateral condyle of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type I or II
S72426C Nondisplaced fracture of lateral condyle of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type IIIA, IIIB, or IIIC
S72431A Displaced fracture of medial condyle of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72431B Displaced fracture of medial condyle of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72431C Displaced fracture of medial condyle of right femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S72432A Displaced fracture of medial condyle of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72432B Displaced fracture of medial condyle of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72432C Displaced fracture of medial condyle of left femur, initial encounter for open fracture type IIIA, IIIB, 170 170 170 Yes Yes Yes No
or IIIC
S72433A Displaced fracture of medial condyle of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72433B Displaced fracture of medial condyle of unspecified femur, initial encounter for open fracture type I 170 170 170 Yes Yes Yes No
or II
S72433C Displaced fracture of medial condyle of unspecified femur, initial encounter for open fracture type 170 170 170 Yes Yes Yes No
IIIA, IIIB, or IIIC
S72434A Nondisplaced fracture of medial condyle of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72434B Nondisplaced fracture of medial condyle of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No

S72434C Nondisplaced fracture of medial condyle of right femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72435A Nondisplaced fracture of medial condyle of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72435B Nondisplaced fracture of medial condyle of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72435C Nondisplaced fracture of medial condyle of left femur, initial encounter for open fracture type IIIA, 170 170 170 Yes Yes Yes No
IIIB, or IIIC
S72436A Nondisplaced fracture of medial condyle of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72436B Nondisplaced fracture of medial condyle of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type I or II
S72436C Nondisplaced fracture of medial condyle of unspecified femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type IIIA, IIIB, or IIIC
S72441A Displaced fracture of lower epiphysis (separation) of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72441B Displaced fracture of lower epiphysis (separation) of right femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type I or II
S72441C Displaced fracture of lower epiphysis (separation) of right femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type IIIA, IIIB, or IIIC
S72442A Displaced fracture of lower epiphysis (separation) of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72442B Displaced fracture of lower epiphysis (separation) of left femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type I or II
S72442C Displaced fracture of lower epiphysis (separation) of left femur, initial encounter for open fracture 170 170 170 Yes Yes Yes No
type IIIA, IIIB, or IIIC
S72443A Displaced fracture of lower epiphysis (separation) of unspecified femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S72443B Displaced fracture of lower epiphysis (separation) of unspecified femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type I or II

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 208 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S72443C Displaced fracture of lower epiphysis (separation) of unspecified femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type IIIA, IIIB, or IIIC
S72444A Nondisplaced fracture of lower epiphysis (separation) of right femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S72444B Nondisplaced fracture of lower epiphysis (separation) of right femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type I or II
S72444C Nondisplaced fracture of lower epiphysis (separation) of right femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type IIIA, IIIB, or IIIC
S72445A Nondisplaced fracture of lower epiphysis (separation) of left femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S72445B Nondisplaced fracture of lower epiphysis (separation) of left femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type I or II
S72445C Nondisplaced fracture of lower epiphysis (separation) of left femur, initial encounter for open 170 170 170 Yes Yes Yes No
fracture type IIIA, IIIB, or IIIC
S72446A Nondisplaced fracture of lower epiphysis (separation) of unspecified femur, initial encounter for 170 170 170 Yes Yes Yes No
closed fracture
S72446B Nondisplaced fracture of lower epiphysis (separation) of unspecified femur, initial encounter for 170 170 170 Yes Yes Yes No
open fracture type I or II
S72446C Nondisplaced fracture of lower epiphysis (separation) of unspecified femur, initial encounter for 170 170 170 Yes Yes Yes No
open fracture type IIIA, IIIB, or IIIC
S72451A Displaced supracondylar fracture without intracondylar extension of lower end of right femur, initial 170 170 170 Yes Yes Yes No
encounter for closed fracture
S72451B Displaced supracondylar fracture without intracondylar extension of lower end of right femur, initial 170 170 170 Yes Yes Yes No
encounter for open fracture type I or II
S72451C Displaced supracondylar fracture without intracondylar extension of lower end of right femur, initial 170 170 170 Yes Yes Yes No
encounter for open fracture type IIIA, IIIB, or IIIC
S72452A Displaced supracondylar fracture without intracondylar extension of lower end of left femur, initial 170 170 170 Yes Yes Yes No
encounter for closed fracture
S72452B Displaced supracondylar fracture without intracondylar extension of lower end of left femur, initial 170 170 170 Yes Yes Yes No
encounter for open fracture type I or II
S72452C Displaced supracondylar fracture without intracondylar extension of lower end of left femur, initial 170 170 170 Yes Yes Yes No
encounter for open fracture type IIIA, IIIB, or IIIC
S72453A Displaced supracondylar fracture without intracondylar extension of lower end of unspecified femur, 170 170 170 Yes Yes Yes No
initial encounter for closed fracture
S72453B Displaced supracondylar fracture without intracondylar extension of lower end of unspecified femur, 170 170 170 Yes Yes Yes No
initial encounter for open fracture type I or II
S72453C Displaced supracondylar fracture without intracondylar extension of lower end of unspecified femur, 170 170 170 Yes Yes Yes No
initial encounter for open fracture type IIIA, IIIB, or IIIC
S72454A Nondisplaced supracondylar fracture without intracondylar extension of lower end of right femur, 170 170 170 Yes Yes Yes No
initial encounter for closed fracture
S72454B Nondisplaced supracondylar fracture without intracondylar extension of lower end of right femur, 170 170 170 Yes Yes Yes No
initial encounter for open fracture type I or II
S72454C Nondisplaced supracondylar fracture without intracondylar extension of lower end of right femur, 170 170 170 Yes Yes Yes No
initial encounter for open fracture type IIIA, IIIB, or IIIC
S72455A Nondisplaced supracondylar fracture without intracondylar extension of lower end of left femur, 170 170 170 Yes Yes Yes No
initial encounter for closed fracture
S72455B Nondisplaced supracondylar fracture without intracondylar extension of lower end of left femur, 170 170 170 Yes Yes Yes No
initial encounter for open fracture type I or II
S72455C Nondisplaced supracondylar fracture without intracondylar extension of lower end of left femur, 170 170 170 Yes Yes Yes No
initial encounter for open fracture type IIIA, IIIB, or IIIC

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 209 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S72456A Nondisplaced supracondylar fracture without intracondylar extension of lower end of unspecified 170 170 170 Yes Yes Yes No
femur, initial encounter for closed fracture
S72456B Nondisplaced supracondylar fracture without intracondylar extension of lower end of unspecified 170 170 170 Yes Yes Yes No
femur, initial encounter for open fracture type I or II
S72456C Nondisplaced supracondylar fracture without intracondylar extension of lower end of unspecified 170 170 170 Yes Yes Yes No
femur, initial encounter for open fracture type IIIA, IIIB, or IIIC
S72461A Displaced supracondylar fracture with intracondylar extension of lower end of right femur, initial 170 170 170 Yes Yes Yes No
encounter for closed fracture
S72461B Displaced supracondylar fracture with intracondylar extension of lower end of right femur, initial 170 170 170 Yes Yes Yes No
encounter for open fracture type I or II
S72461C Displaced supracondylar fracture with intracondylar extension of lower end of right femur, initial 170 170 170 Yes Yes Yes No
encounter for open fracture type IIIA, IIIB, or IIIC
S72462A Displaced supracondylar fracture with intracondylar extension of lower end of left femur, initial 170 170 170 Yes Yes Yes No
encounter for closed fracture
S72462B Displaced supracondylar fracture with intracondylar extension of lower end of left femur, initial 170 170 170 Yes Yes Yes No
encounter for open fracture type I or II
S72462C Displaced supracondylar fracture with intracondylar extension of lower end of left femur, initial 170 170 170 Yes Yes Yes No
encounter for open fracture type IIIA, IIIB, or IIIC
S72463A Displaced supracondylar fracture with intracondylar extension of lower end of unspecified femur, 170 170 170 Yes Yes Yes No
initial encounter for closed fracture
S72463B Displaced supracondylar fracture with intracondylar extension of lower end of unspecified femur, 170 170 170 Yes Yes Yes No
initial encounter for open fracture type I or II
S72463C Displaced supracondylar fracture with intracondylar extension of lower end of unspecified femur, 170 170 170 Yes Yes Yes No
initial encounter for open fracture type IIIA, IIIB, or IIIC
S72464A Nondisplaced supracondylar fracture with intracondylar extension of lower end of right femur, initial 170 170 170 Yes Yes Yes No
encounter for closed fracture
S72464B Nondisplaced supracondylar fracture with intracondylar extension of lower end of right femur, initial 170 170 170 Yes Yes Yes No
encounter for open fracture type I or II
S72464C Nondisplaced supracondylar fracture with intracondylar extension of lower end of right femur, initial 170 170 170 Yes Yes Yes No
encounter for open fracture type IIIA, IIIB, or IIIC
S72465A Nondisplaced supracondylar fracture with intracondylar extension of lower end of left femur, initial 170 170 170 Yes Yes Yes No
encounter for closed fracture
S72465B Nondisplaced supracondylar fracture with intracondylar extension of lower end of left femur, initial 170 170 170 Yes Yes Yes No
encounter for open fracture type I or II
S72465C Nondisplaced supracondylar fracture with intracondylar extension of lower end of left femur, initial 170 170 170 Yes Yes Yes No
encounter for open fracture type IIIA, IIIB, or IIIC
S72466A Nondisplaced supracondylar fracture with intracondylar extension of lower end of unspecified 170 170 170 Yes Yes Yes No
femur, initial encounter for closed fracture
S72466B Nondisplaced supracondylar fracture with intracondylar extension of lower end of unspecified 170 170 170 Yes Yes Yes No
femur, initial encounter for open fracture type I or II
S72466C Nondisplaced supracondylar fracture with intracondylar extension of lower end of unspecified 170 170 170 Yes Yes Yes No
femur, initial encounter for open fracture type IIIA, IIIB, or IIIC
S72471A Torus fracture of lower end of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72472A Torus fracture of lower end of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72479A Torus fracture of lower end of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72491A Other fracture of lower end of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72491B Other fracture of lower end of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72491C Other fracture of lower end of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No
S72492A Other fracture of lower end of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72492B Other fracture of lower end of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72492C Other fracture of lower end of left femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 210 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S72499A Other fracture of lower end of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S72499B Other fracture of lower end of unspecified femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S72499C Other fracture of lower end of unspecified femur, initial encounter for open fracture type IIIA, IIIB, or 170 170 170 Yes Yes Yes No
IIIC
S728X1A Other fracture of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S728X1B Other fracture of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S728X1C Other fracture of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No
S728X2A Other fracture of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S728X2B Other fracture of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S728X2C Other fracture of left femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No
S728X9A Other fracture of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S728X9B Other fracture of unspecified femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S728X9C Other fracture of unspecified femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No
S7290XA Unspecified fracture of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S7290XB Unspecified fracture of unspecified femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S7290XC Unspecified fracture of unspecified femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No
S7291XA Unspecified fracture of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S7291XB Unspecified fracture of right femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S7291XC Unspecified fracture of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No
S7292XA Unspecified fracture of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S7292XB Unspecified fracture of left femur, initial encounter for open fracture type I or II 170 170 170 Yes Yes Yes No
S7292XC Unspecified fracture of left femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 170 170 170 Yes Yes Yes No
S73001A Unspecified subluxation of right hip, initial encounter 170 170 170 Yes Yes Yes No
S73002A Unspecified subluxation of left hip, initial encounter 170 170 170 Yes Yes Yes No
S73003A Unspecified subluxation of unspecified hip, initial encounter 170 170 170 Yes Yes Yes No
S73004A Unspecified dislocation of right hip, initial encounter 170 170 170 Yes Yes Yes No
S73005A Unspecified dislocation of left hip, initial encounter 170 170 170 Yes Yes Yes No
S73006A Unspecified dislocation of unspecified hip, initial encounter 170 170 170 Yes Yes Yes No
S73011A Posterior subluxation of right hip, initial encounter 170 170 170 Yes Yes Yes No
S73012A Posterior subluxation of left hip, initial encounter 170 170 170 Yes Yes Yes No
S73013A Posterior subluxation of unspecified hip, initial encounter 170 170 170 Yes Yes Yes No
S73014A Posterior dislocation of right hip, initial encounter 170 170 170 Yes Yes Yes No
S73015A Posterior dislocation of left hip, initial encounter 170 170 170 Yes Yes Yes No
S73016A Posterior dislocation of unspecified hip, initial encounter 170 170 170 Yes Yes Yes No
S73021A Obturator subluxation of right hip, initial encounter 170 170 170 Yes Yes Yes No
S73022A Obturator subluxation of left hip, initial encounter 170 170 170 Yes Yes Yes No
S73023A Obturator subluxation of unspecified hip, initial encounter 170 170 170 Yes Yes Yes No
S73024A Obturator dislocation of right hip, initial encounter 170 170 170 Yes Yes Yes No
S73025A Obturator dislocation of left hip, initial encounter 170 170 170 Yes Yes Yes No
S73026A Obturator dislocation of unspecified hip, initial encounter 170 170 170 Yes Yes Yes No
S73031A Other anterior subluxation of right hip, initial encounter 170 170 170 Yes Yes Yes No
S73032A Other anterior subluxation of left hip, initial encounter 170 170 170 Yes Yes Yes No
S73033A Other anterior subluxation of unspecified hip, initial encounter 170 170 170 Yes Yes Yes No
S73034A Other anterior dislocation of right hip, initial encounter 170 170 170 Yes Yes Yes No
S73035A Other anterior dislocation of left hip, initial encounter 170 170 170 Yes Yes Yes No
S73036A Other anterior dislocation of unspecified hip, initial encounter 170 170 170 Yes Yes Yes No
S73041A Central subluxation of right hip, initial encounter 170 170 170 Yes Yes Yes No
S73042A Central subluxation of left hip, initial encounter 170 170 170 Yes Yes Yes No
S73043A Central subluxation of unspecified hip, initial encounter 170 170 170 Yes Yes Yes No
S73044A Central dislocation of right hip, initial encounter 170 170 170 Yes Yes Yes No
S73045A Central dislocation of left hip, initial encounter 170 170 170 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 211 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S73046A Central dislocation of unspecified hip, initial encounter 170 170 170 Yes Yes Yes No
S78011A Complete traumatic amputation at right hip joint, initial encounter 173 173 173 Yes Yes Yes No
S78011D Complete traumatic amputation at right hip joint, subsequent encounter 189 189 189 Yes Yes Yes No
S78011S Complete traumatic amputation at right hip joint, sequela 189 189 189 Yes Yes Yes No
S78012A Complete traumatic amputation at left hip joint, initial encounter 173 173 173 Yes Yes Yes No
S78012D Complete traumatic amputation at left hip joint, subsequent encounter 189 189 189 Yes Yes Yes No
S78012S Complete traumatic amputation at left hip joint, sequela 189 189 189 Yes Yes Yes No
S78019A Complete traumatic amputation at unspecified hip joint, initial encounter 173 173 173 Yes Yes Yes No
S78019D Complete traumatic amputation at unspecified hip joint, subsequent encounter 189 189 189 Yes Yes Yes No
S78019S Complete traumatic amputation at unspecified hip joint, sequela 189 189 189 Yes Yes Yes No
S78021A Partial traumatic amputation at right hip joint, initial encounter 173 173 173 Yes Yes Yes No
S78021D Partial traumatic amputation at right hip joint, subsequent encounter 189 189 189 Yes Yes Yes No
S78021S Partial traumatic amputation at right hip joint, sequela 189 189 189 Yes Yes Yes No
S78022A Partial traumatic amputation at left hip joint, initial encounter 173 173 173 Yes Yes Yes No
S78022D Partial traumatic amputation at left hip joint, subsequent encounter 189 189 189 Yes Yes Yes No
S78022S Partial traumatic amputation at left hip joint, sequela 189 189 189 Yes Yes Yes No
S78029A Partial traumatic amputation at unspecified hip joint, initial encounter 173 173 173 Yes Yes Yes No
S78029D Partial traumatic amputation at unspecified hip joint, subsequent encounter 189 189 189 Yes Yes Yes No
S78029S Partial traumatic amputation at unspecified hip joint, sequela 189 189 189 Yes Yes Yes No
S78111A Complete traumatic amputation at level between right hip and knee, initial encounter 173 173 173 Yes Yes Yes No
S78111D Complete traumatic amputation at level between right hip and knee, subsequent encounter 189 189 189 Yes Yes Yes No
S78111S Complete traumatic amputation at level between right hip and knee, sequela 189 189 189 Yes Yes Yes No
S78112A Complete traumatic amputation at level between left hip and knee, initial encounter 173 173 173 Yes Yes Yes No
S78112D Complete traumatic amputation at level between left hip and knee, subsequent encounter 189 189 189 Yes Yes Yes No
S78112S Complete traumatic amputation at level between left hip and knee, sequela 189 189 189 Yes Yes Yes No
S78119A Complete traumatic amputation at level between unspecified hip and knee, initial encounter 173 173 173 Yes Yes Yes No
S78119D Complete traumatic amputation at level between unspecified hip and knee, subsequent encounter 189 189 189 Yes Yes Yes No
S78119S Complete traumatic amputation at level between unspecified hip and knee, sequela 189 189 189 Yes Yes Yes No
S78121A Partial traumatic amputation at level between right hip and knee, initial encounter 173 173 173 Yes Yes Yes No
S78121D Partial traumatic amputation at level between right hip and knee, subsequent encounter 189 189 189 Yes Yes Yes No
S78121S Partial traumatic amputation at level between right hip and knee, sequela 189 189 189 Yes Yes Yes No
S78122A Partial traumatic amputation at level between left hip and knee, initial encounter 173 173 173 Yes Yes Yes No
S78122D Partial traumatic amputation at level between left hip and knee, subsequent encounter 189 189 189 Yes Yes Yes No
S78122S Partial traumatic amputation at level between left hip and knee, sequela 189 189 189 Yes Yes Yes No
S78129A Partial traumatic amputation at level between unspecified hip and knee, initial encounter 173 173 173 Yes Yes Yes No
S78129D Partial traumatic amputation at level between unspecified hip and knee, subsequent encounter 189 189 189 Yes Yes Yes No
S78129S Partial traumatic amputation at level between unspecified hip and knee, sequela 189 189 189 Yes Yes Yes No
S78911A Complete traumatic amputation of right hip and thigh, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S78911D Complete traumatic amputation of right hip and thigh, level unspecified, subsequent encounter 189 189 189 Yes Yes Yes No
S78911S Complete traumatic amputation of right hip and thigh, level unspecified, sequela 189 189 189 Yes Yes Yes No
S78912A Complete traumatic amputation of left hip and thigh, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S78912D Complete traumatic amputation of left hip and thigh, level unspecified, subsequent encounter 189 189 189 Yes Yes Yes No
S78912S Complete traumatic amputation of left hip and thigh, level unspecified, sequela 189 189 189 Yes Yes Yes No
S78919A Complete traumatic amputation of unspecified hip and thigh, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S78919D Complete traumatic amputation of unspecified hip and thigh, level unspecified, subsequent 189 189 189 Yes Yes Yes No
encounter
S78919S Complete traumatic amputation of unspecified hip and thigh, level unspecified, sequela 189 189 189 Yes Yes Yes No
S78921A Partial traumatic amputation of right hip and thigh, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S78921D Partial traumatic amputation of right hip and thigh, level unspecified, subsequent encounter 189 189 189 Yes Yes Yes No
S78921S Partial traumatic amputation of right hip and thigh, level unspecified, sequela 189 189 189 Yes Yes Yes No
S78922A Partial traumatic amputation of left hip and thigh, level unspecified, initial encounter 173 173 173 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 212 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S78922D Partial traumatic amputation of left hip and thigh, level unspecified, subsequent encounter 189 189 189 Yes Yes Yes No
S78922S Partial traumatic amputation of left hip and thigh, level unspecified, sequela 189 189 189 Yes Yes Yes No
S78929A Partial traumatic amputation of unspecified hip and thigh, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S78929D Partial traumatic amputation of unspecified hip and thigh, level unspecified, subsequent encounter 189 189 189 Yes Yes Yes No
S78929S Partial traumatic amputation of unspecified hip and thigh, level unspecified, sequela 189 189 189 Yes Yes Yes No
S79001A Unspecified physeal fracture of upper end of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79002A Unspecified physeal fracture of upper end of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79009A Unspecified physeal fracture of upper end of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79011A Salter-Harris Type I physeal fracture of upper end of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79012A Salter-Harris Type I physeal fracture of upper end of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79019A Salter-Harris Type I physeal fracture of upper end of unspecified femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S79091A Other physeal fracture of upper end of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79092A Other physeal fracture of upper end of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79099A Other physeal fracture of upper end of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79101A Unspecified physeal fracture of lower end of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79102A Unspecified physeal fracture of lower end of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79109A Unspecified physeal fracture of lower end of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79111A Salter-Harris Type I physeal fracture of lower end of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79112A Salter-Harris Type I physeal fracture of lower end of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79119A Salter-Harris Type I physeal fracture of lower end of unspecified femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S79121A Salter-Harris Type II physeal fracture of lower end of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79122A Salter-Harris Type II physeal fracture of lower end of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79129A Salter-Harris Type II physeal fracture of lower end of unspecified femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S79131A Salter-Harris Type III physeal fracture of lower end of right femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S79132A Salter-Harris Type III physeal fracture of lower end of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79139A Salter-Harris Type III physeal fracture of lower end of unspecified femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S79141A Salter-Harris Type IV physeal fracture of lower end of right femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S79142A Salter-Harris Type IV physeal fracture of lower end of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79149A Salter-Harris Type IV physeal fracture of lower end of unspecified femur, initial encounter for closed 170 170 170 Yes Yes Yes No
fracture
S79191A Other physeal fracture of lower end of right femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79192A Other physeal fracture of lower end of left femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S79199A Other physeal fracture of lower end of unspecified femur, initial encounter for closed fracture 170 170 170 Yes Yes Yes No
S88011A Complete traumatic amputation at knee level, right lower leg, initial encounter 173 173 173 Yes Yes Yes No
S88011D Complete traumatic amputation at knee level, right lower leg, subsequent encounter 189 189 189 Yes Yes Yes No
S88011S Complete traumatic amputation at knee level, right lower leg, sequela 189 189 189 Yes Yes Yes No
S88012A Complete traumatic amputation at knee level, left lower leg, initial encounter 173 173 173 Yes Yes Yes No
S88012D Complete traumatic amputation at knee level, left lower leg, subsequent encounter 189 189 189 Yes Yes Yes No
S88012S Complete traumatic amputation at knee level, left lower leg, sequela 189 189 189 Yes Yes Yes No
S88019A Complete traumatic amputation at knee level, unspecified lower leg, initial encounter 173 173 173 Yes Yes Yes No
S88019D Complete traumatic amputation at knee level, unspecified lower leg, subsequent encounter 189 189 189 Yes Yes Yes No
S88019S Complete traumatic amputation at knee level, unspecified lower leg, sequela 189 189 189 Yes Yes Yes No
S88021A Partial traumatic amputation at knee level, right lower leg, initial encounter 173 173 173 Yes Yes Yes No
S88021D Partial traumatic amputation at knee level, right lower leg, subsequent encounter 189 189 189 Yes Yes Yes No
S88021S Partial traumatic amputation at knee level, right lower leg, sequela 189 189 189 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 213 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S88022A Partial traumatic amputation at knee level, left lower leg, initial encounter 173 173 173 Yes Yes Yes No
S88022D Partial traumatic amputation at knee level, left lower leg, subsequent encounter 189 189 189 Yes Yes Yes No
S88022S Partial traumatic amputation at knee level, left lower leg, sequela 189 189 189 Yes Yes Yes No
S88029A Partial traumatic amputation at knee level, unspecified lower leg, initial encounter 173 173 173 Yes Yes Yes No
S88029D Partial traumatic amputation at knee level, unspecified lower leg, subsequent encounter 189 189 189 Yes Yes Yes No
S88029S Partial traumatic amputation at knee level, unspecified lower leg, sequela 189 189 189 Yes Yes Yes No
S88111A Complete traumatic amputation at level between knee and ankle, right lower leg, initial encounter 173 173 173 Yes Yes Yes No
S88111D Complete traumatic amputation at level between knee and ankle, right lower leg, subsequent 189 189 189 Yes Yes Yes No
encounter
S88111S Complete traumatic amputation at level between knee and ankle, right lower leg, sequela 189 189 189 Yes Yes Yes No
S88112A Complete traumatic amputation at level between knee and ankle, left lower leg, initial encounter 173 173 173 Yes Yes Yes No
S88112D Complete traumatic amputation at level between knee and ankle, left lower leg, subsequent 189 189 189 Yes Yes Yes No
encounter
S88112S Complete traumatic amputation at level between knee and ankle, left lower leg, sequela 189 189 189 Yes Yes Yes No
S88119A Complete traumatic amputation at level between knee and ankle, unspecified lower leg, initial 173 173 173 Yes Yes Yes No
encounter
S88119D Complete traumatic amputation at level between knee and ankle, unspecified lower leg, subsequent 189 189 189 Yes Yes Yes No
encounter
S88119S Complete traumatic amputation at level between knee and ankle, unspecified lower leg, sequela 189 189 189 Yes Yes Yes No
S88121A Partial traumatic amputation at level between knee and ankle, right lower leg, initial encounter 173 173 173 Yes Yes Yes No
S88121D Partial traumatic amputation at level between knee and ankle, right lower leg, subsequent encounter 189 189 189 Yes Yes Yes No
S88121S Partial traumatic amputation at level between knee and ankle, right lower leg, sequela 189 189 189 Yes Yes Yes No
S88122A Partial traumatic amputation at level between knee and ankle, left lower leg, initial encounter 173 173 173 Yes Yes Yes No
S88122D Partial traumatic amputation at level between knee and ankle, left lower leg, subsequent encounter 189 189 189 Yes Yes Yes No
S88122S Partial traumatic amputation at level between knee and ankle, left lower leg, sequela 189 189 189 Yes Yes Yes No
S88129A Partial traumatic amputation at level between knee and ankle, unspecified lower leg, initial 173 173 173 Yes Yes Yes No
encounter
S88129D Partial traumatic amputation at level between knee and ankle, unspecified lower leg, subsequent 189 189 189 Yes Yes Yes No
encounter
S88129S Partial traumatic amputation at level between knee and ankle, unspecified lower leg, sequela 189 189 189 Yes Yes Yes No
S88911A Complete traumatic amputation of right lower leg, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S88911D Complete traumatic amputation of right lower leg, level unspecified, subsequent encounter 189 189 189 Yes Yes Yes No
S88911S Complete traumatic amputation of right lower leg, level unspecified, sequela 189 189 189 Yes Yes Yes No
S88912A Complete traumatic amputation of left lower leg, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S88912D Complete traumatic amputation of left lower leg, level unspecified, subsequent encounter 189 189 189 Yes Yes Yes No
S88912S Complete traumatic amputation of left lower leg, level unspecified, sequela 189 189 189 Yes Yes Yes No
S88919A Complete traumatic amputation of unspecified lower leg, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S88919D Complete traumatic amputation of unspecified lower leg, level unspecified, subsequent encounter 189 189 189 Yes Yes Yes No
S88919S Complete traumatic amputation of unspecified lower leg, level unspecified, sequela 189 189 189 Yes Yes Yes No
S88921A Partial traumatic amputation of right lower leg, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S88921D Partial traumatic amputation of right lower leg, level unspecified, subsequent encounter 189 189 189 Yes Yes Yes No
S88921S Partial traumatic amputation of right lower leg, level unspecified, sequela 189 189 189 Yes Yes Yes No
S88922A Partial traumatic amputation of left lower leg, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S88922D Partial traumatic amputation of left lower leg, level unspecified, subsequent encounter 189 189 189 Yes Yes Yes No
S88922S Partial traumatic amputation of left lower leg, level unspecified, sequela 189 189 189 Yes Yes Yes No
S88929A Partial traumatic amputation of unspecified lower leg, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S88929D Partial traumatic amputation of unspecified lower leg, level unspecified, subsequent encounter 189 189 189 Yes Yes Yes No
S88929S Partial traumatic amputation of unspecified lower leg, level unspecified, sequela 189 189 189 Yes Yes Yes No
S98011A Complete traumatic amputation of right foot at ankle level, initial encounter 173 173 173 Yes Yes Yes No
S98011D Complete traumatic amputation of right foot at ankle level, subsequent encounter 189 189 189 Yes Yes Yes No
S98011S Complete traumatic amputation of right foot at ankle level, sequela 189 189 189 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 214 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S98012A Complete traumatic amputation of left foot at ankle level, initial encounter 173 173 173 Yes Yes Yes No
S98012D Complete traumatic amputation of left foot at ankle level, subsequent encounter 189 189 189 Yes Yes Yes No
S98012S Complete traumatic amputation of left foot at ankle level, sequela 189 189 189 Yes Yes Yes No
S98019A Complete traumatic amputation of unspecified foot at ankle level, initial encounter 173 173 173 Yes Yes Yes No
S98019D Complete traumatic amputation of unspecified foot at ankle level, subsequent encounter 189 189 189 Yes Yes Yes No
S98019S Complete traumatic amputation of unspecified foot at ankle level, sequela 189 189 189 Yes Yes Yes No
S98021A Partial traumatic amputation of right foot at ankle level, initial encounter 173 173 173 Yes Yes Yes No
S98021D Partial traumatic amputation of right foot at ankle level, subsequent encounter 189 189 189 Yes Yes Yes No
S98021S Partial traumatic amputation of right foot at ankle level, sequela 189 189 189 Yes Yes Yes No
S98022A Partial traumatic amputation of left foot at ankle level, initial encounter 173 173 173 Yes Yes Yes No
S98022D Partial traumatic amputation of left foot at ankle level, subsequent encounter 189 189 189 Yes Yes Yes No
S98022S Partial traumatic amputation of left foot at ankle level, sequela 189 189 189 Yes Yes Yes No
S98029A Partial traumatic amputation of unspecified foot at ankle level, initial encounter 173 173 173 Yes Yes Yes No
S98029D Partial traumatic amputation of unspecified foot at ankle level, subsequent encounter 189 189 189 Yes Yes Yes No
S98029S Partial traumatic amputation of unspecified foot at ankle level, sequela 189 189 189 Yes Yes Yes No
S98111A Complete traumatic amputation of right great toe, initial encounter 173 173 173 Yes Yes Yes No
S98111D Complete traumatic amputation of right great toe, subsequent encounter 189 189 189 Yes Yes Yes No
S98111S Complete traumatic amputation of right great toe, sequela 189 189 189 Yes Yes Yes No
S98112A Complete traumatic amputation of left great toe, initial encounter 173 173 173 Yes Yes Yes No
S98112D Complete traumatic amputation of left great toe, subsequent encounter 189 189 189 Yes Yes Yes No
S98112S Complete traumatic amputation of left great toe, sequela 189 189 189 Yes Yes Yes No
S98119A Complete traumatic amputation of unspecified great toe, initial encounter 173 173 173 Yes Yes Yes No
S98119D Complete traumatic amputation of unspecified great toe, subsequent encounter 189 189 189 Yes Yes Yes No
S98119S Complete traumatic amputation of unspecified great toe, sequela 189 189 189 Yes Yes Yes No
S98121A Partial traumatic amputation of right great toe, initial encounter 173 173 173 Yes Yes Yes No
S98121D Partial traumatic amputation of right great toe, subsequent encounter 189 189 189 Yes Yes Yes No
S98121S Partial traumatic amputation of right great toe, sequela 189 189 189 Yes Yes Yes No
S98122A Partial traumatic amputation of left great toe, initial encounter 173 173 173 Yes Yes Yes No
S98122D Partial traumatic amputation of left great toe, subsequent encounter 189 189 189 Yes Yes Yes No
S98122S Partial traumatic amputation of left great toe, sequela 189 189 189 Yes Yes Yes No
S98129A Partial traumatic amputation of unspecified great toe, initial encounter 173 173 173 Yes Yes Yes No
S98129D Partial traumatic amputation of unspecified great toe, subsequent encounter 189 189 189 Yes Yes Yes No
S98129S Partial traumatic amputation of unspecified great toe, sequela 189 189 189 Yes Yes Yes No
S98131A Complete traumatic amputation of one right lesser toe, initial encounter 173 173 173 Yes Yes Yes No
S98131D Complete traumatic amputation of one right lesser toe, subsequent encounter 189 189 189 Yes Yes Yes No
S98131S Complete traumatic amputation of one right lesser toe, sequela 189 189 189 Yes Yes Yes No
S98132A Complete traumatic amputation of one left lesser toe, initial encounter 173 173 173 Yes Yes Yes No
S98132D Complete traumatic amputation of one left lesser toe, subsequent encounter 189 189 189 Yes Yes Yes No
S98132S Complete traumatic amputation of one left lesser toe, sequela 189 189 189 Yes Yes Yes No
S98139A Complete traumatic amputation of one unspecified lesser toe, initial encounter 173 173 173 Yes Yes Yes No
S98139D Complete traumatic amputation of one unspecified lesser toe, subsequent encounter 189 189 189 Yes Yes Yes No
S98139S Complete traumatic amputation of one unspecified lesser toe, sequela 189 189 189 Yes Yes Yes No
S98141A Partial traumatic amputation of one right lesser toe, initial encounter 173 173 173 Yes Yes Yes No
S98141D Partial traumatic amputation of one right lesser toe, subsequent encounter 189 189 189 Yes Yes Yes No
S98141S Partial traumatic amputation of one right lesser toe, sequela 189 189 189 Yes Yes Yes No
S98142A Partial traumatic amputation of one left lesser toe, initial encounter 173 173 173 Yes Yes Yes No
S98142D Partial traumatic amputation of one left lesser toe, subsequent encounter 189 189 189 Yes Yes Yes No
S98142S Partial traumatic amputation of one left lesser toe, sequela 189 189 189 Yes Yes Yes No
S98149A Partial traumatic amputation of one unspecified lesser toe, initial encounter 173 173 173 Yes Yes Yes No
S98149D Partial traumatic amputation of one unspecified lesser toe, subsequent encounter 189 189 189 Yes Yes Yes No
S98149S Partial traumatic amputation of one unspecified lesser toe, sequela 189 189 189 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 215 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S98211A Complete traumatic amputation of two or more right lesser toes, initial encounter 173 173 173 Yes Yes Yes No
S98211D Complete traumatic amputation of two or more right lesser toes, subsequent encounter 189 189 189 Yes Yes Yes No
S98211S Complete traumatic amputation of two or more right lesser toes, sequela 189 189 189 Yes Yes Yes No
S98212A Complete traumatic amputation of two or more left lesser toes, initial encounter 173 173 173 Yes Yes Yes No
S98212D Complete traumatic amputation of two or more left lesser toes, subsequent encounter 189 189 189 Yes Yes Yes No
S98212S Complete traumatic amputation of two or more left lesser toes, sequela 189 189 189 Yes Yes Yes No
S98219A Complete traumatic amputation of two or more unspecified lesser toes, initial encounter 173 173 173 Yes Yes Yes No
S98219D Complete traumatic amputation of two or more unspecified lesser toes, subsequent encounter 189 189 189 Yes Yes Yes No
S98219S Complete traumatic amputation of two or more unspecified lesser toes, sequela 189 189 189 Yes Yes Yes No
S98221A Partial traumatic amputation of two or more right lesser toes, initial encounter 173 173 173 Yes Yes Yes No
S98221D Partial traumatic amputation of two or more right lesser toes, subsequent encounter 189 189 189 Yes Yes Yes No
S98221S Partial traumatic amputation of two or more right lesser toes, sequela 189 189 189 Yes Yes Yes No
S98222A Partial traumatic amputation of two or more left lesser toes, initial encounter 173 173 173 Yes Yes Yes No
S98222D Partial traumatic amputation of two or more left lesser toes, subsequent encounter 189 189 189 Yes Yes Yes No
S98222S Partial traumatic amputation of two or more left lesser toes, sequela 189 189 189 Yes Yes Yes No
S98229A Partial traumatic amputation of two or more unspecified lesser toes, initial encounter 173 173 173 Yes Yes Yes No
S98229D Partial traumatic amputation of two or more unspecified lesser toes, subsequent encounter 189 189 189 Yes Yes Yes No
S98229S Partial traumatic amputation of two or more unspecified lesser toes, sequela 189 189 189 Yes Yes Yes No
S98311A Complete traumatic amputation of right midfoot, initial encounter 173 173 173 Yes Yes Yes No
S98311D Complete traumatic amputation of right midfoot, subsequent encounter 189 189 189 Yes Yes Yes No
S98311S Complete traumatic amputation of right midfoot, sequela 189 189 189 Yes Yes Yes No
S98312A Complete traumatic amputation of left midfoot, initial encounter 173 173 173 Yes Yes Yes No
S98312D Complete traumatic amputation of left midfoot, subsequent encounter 189 189 189 Yes Yes Yes No
S98312S Complete traumatic amputation of left midfoot, sequela 189 189 189 Yes Yes Yes No
S98319A Complete traumatic amputation of unspecified midfoot, initial encounter 173 173 173 Yes Yes Yes No
S98319D Complete traumatic amputation of unspecified midfoot, subsequent encounter 189 189 189 Yes Yes Yes No
S98319S Complete traumatic amputation of unspecified midfoot, sequela 189 189 189 Yes Yes Yes No
S98321A Partial traumatic amputation of right midfoot, initial encounter 173 173 173 Yes Yes Yes No
S98321D Partial traumatic amputation of right midfoot, subsequent encounter 189 189 189 Yes Yes Yes No
S98321S Partial traumatic amputation of right midfoot, sequela 189 189 189 Yes Yes Yes No
S98322A Partial traumatic amputation of left midfoot, initial encounter 173 173 173 Yes Yes Yes No
S98322D Partial traumatic amputation of left midfoot, subsequent encounter 189 189 189 Yes Yes Yes No
S98322S Partial traumatic amputation of left midfoot, sequela 189 189 189 Yes Yes Yes No
S98329A Partial traumatic amputation of unspecified midfoot, initial encounter 173 173 173 Yes Yes Yes No
S98329D Partial traumatic amputation of unspecified midfoot, subsequent encounter 189 189 189 Yes Yes Yes No
S98329S Partial traumatic amputation of unspecified midfoot, sequela 189 189 189 Yes Yes Yes No
S98911A Complete traumatic amputation of right foot, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S98911D Complete traumatic amputation of right foot, level unspecified, subsequent encounter 189 189 189 Yes Yes Yes No
S98911S Complete traumatic amputation of right foot, level unspecified, sequela 189 189 189 Yes Yes Yes No
S98912A Complete traumatic amputation of left foot, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S98912D Complete traumatic amputation of left foot, level unspecified, subsequent encounter 189 189 189 Yes Yes Yes No
S98912S Complete traumatic amputation of left foot, level unspecified, sequela 189 189 189 Yes Yes Yes No
S98919A Complete traumatic amputation of unspecified foot, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S98919D Complete traumatic amputation of unspecified foot, level unspecified, subsequent encounter 189 189 189 Yes Yes Yes No
S98919S Complete traumatic amputation of unspecified foot, level unspecified, sequela 189 189 189 Yes Yes Yes No
S98921A Partial traumatic amputation of right foot, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S98921D Partial traumatic amputation of right foot, level unspecified, subsequent encounter 189 189 189 Yes Yes Yes No
S98921S Partial traumatic amputation of right foot, level unspecified, sequela 189 189 189 Yes Yes Yes No
S98922A Partial traumatic amputation of left foot, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S98922D Partial traumatic amputation of left foot, level unspecified, subsequent encounter 189 189 189 Yes Yes Yes No
S98922S Partial traumatic amputation of left foot, level unspecified, sequela 189 189 189 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 216 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

S98929A Partial traumatic amputation of unspecified foot, level unspecified, initial encounter 173 173 173 Yes Yes Yes No
S98929D Partial traumatic amputation of unspecified foot, level unspecified, subsequent encounter 189 189 189 Yes Yes Yes No
S98929S Partial traumatic amputation of unspecified foot, level unspecified, sequela 189 189 189 Yes Yes Yes No
T1491XA Suicide attempt, initial encounter 58 58 59 Yes Yes Yes No
T1491XD Suicide attempt, subsequent encounter 58 58 59 Yes Yes Yes No
T1491XS Suicide attempt, sequela 58 58 59 Yes Yes Yes No
T3111 Burns involving 10-19% of body surface with 10-19% third degree burns 162 162 162 Yes Yes Yes No
T3121 Burns involving 20-29% of body surface with 10-19% third degree burns 162 162 162 Yes Yes Yes No
T3122 Burns involving 20-29% of body surface with 20-29% third degree burns 162 162 162 Yes Yes Yes No
T3131 Burns involving 30-39% of body surface with 10-19% third degree burns 162 162 162 Yes Yes Yes No
T3132 Burns involving 30-39% of body surface with 20-29% third degree burns 162 162 162 Yes Yes Yes No
T3133 Burns involving 30-39% of body surface with 30-39% third degree burns 162 162 162 Yes Yes Yes No
T3141 Burns involving 40-49% of body surface with 10-19% third degree burns 162 162 162 Yes Yes Yes No
T3142 Burns involving 40-49% of body surface with 20-29% third degree burns 162 162 162 Yes Yes Yes No
T3143 Burns involving 40-49% of body surface with 30-39% third degree burns 162 162 162 Yes Yes Yes No
T3144 Burns involving 40-49% of body surface with 40-49% third degree burns 162 162 162 Yes Yes Yes No
T3151 Burns involving 50-59% of body surface with 10-19% third degree burns 162 162 162 Yes Yes Yes No
T3152 Burns involving 50-59% of body surface with 20-29% third degree burns 162 162 162 Yes Yes Yes No
T3153 Burns involving 50-59% of body surface with 30-39% third degree burns 162 162 162 Yes Yes Yes No
T3154 Burns involving 50-59% of body surface with 40-49% third degree burns 162 162 162 Yes Yes Yes No
T3155 Burns involving 50-59% of body surface with 50-59% third degree burns 162 162 162 Yes Yes Yes No
T3161 Burns involving 60-69% of body surface with 10-19% third degree burns 162 162 162 Yes Yes Yes No
T3162 Burns involving 60-69% of body surface with 20-29% third degree burns 162 162 162 Yes Yes Yes No
T3163 Burns involving 60-69% of body surface with 30-39% third degree burns 162 162 162 Yes Yes Yes No
T3164 Burns involving 60-69% of body surface with 40-49% third degree burns 162 162 162 Yes Yes Yes No
T3165 Burns involving 60-69% of body surface with 50-59% third degree burns 162 162 162 Yes Yes Yes No
T3166 Burns involving 60-69% of body surface with 60-69% third degree burns 162 162 162 Yes Yes Yes No
T3171 Burns involving 70-79% of body surface with 10-19% third degree burns 162 162 162 Yes Yes Yes No
T3172 Burns involving 70-79% of body surface with 20-29% third degree burns 162 162 162 Yes Yes Yes No
T3173 Burns involving 70-79% of body surface with 30-39% third degree burns 162 162 162 Yes Yes Yes No
T3174 Burns involving 70-79% of body surface with 40-49% third degree burns 162 162 162 Yes Yes Yes No
T3175 Burns involving 70-79% of body surface with 50-59% third degree burns 162 162 162 Yes Yes Yes No
T3176 Burns involving 70-79% of body surface with 60-69% third degree burns 162 162 162 Yes Yes Yes No
T3177 Burns involving 70-79% of body surface with 70-79% third degree burns 162 162 162 Yes Yes Yes No
T3181 Burns involving 80-89% of body surface with 10-19% third degree burns 162 162 162 Yes Yes Yes No
T3182 Burns involving 80-89% of body surface with 20-29% third degree burns 162 162 162 Yes Yes Yes No
T3183 Burns involving 80-89% of body surface with 30-39% third degree burns 162 162 162 Yes Yes Yes No
T3184 Burns involving 80-89% of body surface with 40-49% third degree burns 162 162 162 Yes Yes Yes No
T3185 Burns involving 80-89% of body surface with 50-59% third degree burns 162 162 162 Yes Yes Yes No
T3186 Burns involving 80-89% of body surface with 60-69% third degree burns 162 162 162 Yes Yes Yes No
T3187 Burns involving 80-89% of body surface with 70-79% third degree burns 162 162 162 Yes Yes Yes No
T3188 Burns involving 80-89% of body surface with 80-89% third degree burns 162 162 162 Yes Yes Yes No
T3191 Burns involving 90% or more of body surface with 10-19% third degree burns 162 162 162 Yes Yes Yes No
T3192 Burns involving 90% or more of body surface with 20-29% third degree burns 162 162 162 Yes Yes Yes No
T3193 Burns involving 90% or more of body surface with 30-39% third degree burns 162 162 162 Yes Yes Yes No
T3194 Burns involving 90% or more of body surface with 40-49% third degree burns 162 162 162 Yes Yes Yes No
T3195 Burns involving 90% or more of body surface with 50-59% third degree burns 162 162 162 Yes Yes Yes No
T3196 Burns involving 90% or more of body surface with 60-69% third degree burns 162 162 162 Yes Yes Yes No
T3197 Burns involving 90% or more of body surface with 70-79% third degree burns 162 162 162 Yes Yes Yes No
T3198 Burns involving 90% or more of body surface with 80-89% third degree burns 162 162 162 Yes Yes Yes No
T3199 Burns involving 90% or more of body surface with 90% or more third degree burns 162 162 162 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 217 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T3211 Corrosions involving 10-19% of body surface with 10-19% third degree corrosion 162 162 162 Yes Yes Yes No
T3221 Corrosions involving 20-29% of body surface with 10-19% third degree corrosion 162 162 162 Yes Yes Yes No
T3222 Corrosions involving 20-29% of body surface with 20-29% third degree corrosion 162 162 162 Yes Yes Yes No
T3231 Corrosions involving 30-39% of body surface with 10-19% third degree corrosion 162 162 162 Yes Yes Yes No
T3232 Corrosions involving 30-39% of body surface with 20-29% third degree corrosion 162 162 162 Yes Yes Yes No
T3233 Corrosions involving 30-39% of body surface with 30-39% third degree corrosion 162 162 162 Yes Yes Yes No
T3241 Corrosions involving 40-49% of body surface with 10-19% third degree corrosion 162 162 162 Yes Yes Yes No
T3242 Corrosions involving 40-49% of body surface with 20-29% third degree corrosion 162 162 162 Yes Yes Yes No
T3243 Corrosions involving 40-49% of body surface with 30-39% third degree corrosion 162 162 162 Yes Yes Yes No
T3244 Corrosions involving 40-49% of body surface with 40-49% third degree corrosion 162 162 162 Yes Yes Yes No
T3251 Corrosions involving 50-59% of body surface with 10-19% third degree corrosion 162 162 162 Yes Yes Yes No
T3252 Corrosions involving 50-59% of body surface with 20-29% third degree corrosion 162 162 162 Yes Yes Yes No
T3253 Corrosions involving 50-59% of body surface with 30-39% third degree corrosion 162 162 162 Yes Yes Yes No
T3254 Corrosions involving 50-59% of body surface with 40-49% third degree corrosion 162 162 162 Yes Yes Yes No
T3255 Corrosions involving 50-59% of body surface with 50-59% third degree corrosion 162 162 162 Yes Yes Yes No
T3261 Corrosions involving 60-69% of body surface with 10-19% third degree corrosion 162 162 162 Yes Yes Yes No
T3262 Corrosions involving 60-69% of body surface with 20-29% third degree corrosion 162 162 162 Yes Yes Yes No
T3263 Corrosions involving 60-69% of body surface with 30-39% third degree corrosion 162 162 162 Yes Yes Yes No
T3264 Corrosions involving 60-69% of body surface with 40-49% third degree corrosion 162 162 162 Yes Yes Yes No
T3265 Corrosions involving 60-69% of body surface with 50-59% third degree corrosion 162 162 162 Yes Yes Yes No
T3266 Corrosions involving 60-69% of body surface with 60-69% third degree corrosion 162 162 162 Yes Yes Yes No
T3271 Corrosions involving 70-79% of body surface with 10-19% third degree corrosion 162 162 162 Yes Yes Yes No
T3272 Corrosions involving 70-79% of body surface with 20-29% third degree corrosion 162 162 162 Yes Yes Yes No
T3273 Corrosions involving 70-79% of body surface with 30-39% third degree corrosion 162 162 162 Yes Yes Yes No
T3274 Corrosions involving 70-79% of body surface with 40-49% third degree corrosion 162 162 162 Yes Yes Yes No
T3275 Corrosions involving 70-79% of body surface with 50-59% third degree corrosion 162 162 162 Yes Yes Yes No
T3276 Corrosions involving 70-79% of body surface with 60-69% third degree corrosion 162 162 162 Yes Yes Yes No
T3277 Corrosions involving 70-79% of body surface with 70-79% third degree corrosion 162 162 162 Yes Yes Yes No
T3281 Corrosions involving 80-89% of body surface with 10-19% third degree corrosion 162 162 162 Yes Yes Yes No
T3282 Corrosions involving 80-89% of body surface with 20-29% third degree corrosion 162 162 162 Yes Yes Yes No
T3283 Corrosions involving 80-89% of body surface with 30-39% third degree corrosion 162 162 162 Yes Yes Yes No
T3284 Corrosions involving 80-89% of body surface with 40-49% third degree corrosion 162 162 162 Yes Yes Yes No
T3285 Corrosions involving 80-89% of body surface with 50-59% third degree corrosion 162 162 162 Yes Yes Yes No
T3286 Corrosions involving 80-89% of body surface with 60-69% third degree corrosion 162 162 162 Yes Yes Yes No
T3287 Corrosions involving 80-89% of body surface with 70-79% third degree corrosion 162 162 162 Yes Yes Yes No
T3288 Corrosions involving 80-89% of body surface with 80-89% third degree corrosion 162 162 162 Yes Yes Yes No
T3291 Corrosions involving 90% or more of body surface with 10-19% third degree corrosion 162 162 162 Yes Yes Yes No
T3292 Corrosions involving 90% or more of body surface with 20-29% third degree corrosion 162 162 162 Yes Yes Yes No
T3293 Corrosions involving 90% or more of body surface with 30-39% third degree corrosion 162 162 162 Yes Yes Yes No
T3294 Corrosions involving 90% or more of body surface with 40-49% third degree corrosion 162 162 162 Yes Yes Yes No
T3295 Corrosions involving 90% or more of body surface with 50-59% third degree corrosion 162 162 162 Yes Yes Yes No
T3296 Corrosions involving 90% or more of body surface with 60-69% third degree corrosion 162 162 162 Yes Yes Yes No
T3297 Corrosions involving 90% or more of body surface with 70-79% third degree corrosion 162 162 162 Yes Yes Yes No
T3298 Corrosions involving 90% or more of body surface with 80-89% third degree corrosion 162 162 162 Yes Yes Yes No
T3299 Corrosions involving 90% or more of body surface with 90% or more third degree corrosion 162 162 162 Yes Yes Yes No
T360X2A Poisoning by penicillins, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T360X2S Poisoning by penicillins, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T361X2A Poisoning by cephalosporins and other beta-lactam antibiotics, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T361X2S Poisoning by cephalosporins and other beta-lactam antibiotics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T362X2A Poisoning by chloramphenicol group, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 218 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T362X2S Poisoning by chloramphenicol group, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T363X2A Poisoning by macrolides, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T363X2S Poisoning by macrolides, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T364X2A Poisoning by tetracyclines, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T364X2S Poisoning by tetracyclines, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T365X2A Poisoning by aminoglycosides, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T365X2S Poisoning by aminoglycosides, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T366X2A Poisoning by rifampicins, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T366X2S Poisoning by rifampicins, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T367X2A Poisoning by antifungal antibiotics, systemically used, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T367X2S Poisoning by antifungal antibiotics, systemically used, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T368X2A Poisoning by other systemic antibiotics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T368X2S Poisoning by other systemic antibiotics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T3692XA Poisoning by unspecified systemic antibiotic, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T3692XS Poisoning by unspecified systemic antibiotic, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T370X2A Poisoning by sulfonamides, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T370X2S Poisoning by sulfonamides, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T371X2A Poisoning by antimycobacterial drugs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T371X2S Poisoning by antimycobacterial drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T372X2A Poisoning by antimalarials and drugs acting on other blood protozoa, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T372X2S Poisoning by antimalarials and drugs acting on other blood protozoa, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T373X2A Poisoning by other antiprotozoal drugs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T373X2S Poisoning by other antiprotozoal drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T374X2A Poisoning by anthelminthics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T374X2S Poisoning by anthelminthics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T375X2A Poisoning by antiviral drugs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T375X2S Poisoning by antiviral drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T378X2A Poisoning by other specified systemic anti-infectives and antiparasitics, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T378X2S Poisoning by other specified systemic anti-infectives and antiparasitics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No

T3792XA Poisoning by unspecified systemic anti-infective and antiparasitics, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T3792XS Poisoning by unspecified systemic anti-infective and antiparasitics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T380X2A Poisoning by glucocorticoids and synthetic analogues, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T380X2S Poisoning by glucocorticoids and synthetic analogues, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T381X2A Poisoning by thyroid hormones and substitutes, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T381X2S Poisoning by thyroid hormones and substitutes, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T382X2A Poisoning by antithyroid drugs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T382X2S Poisoning by antithyroid drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T383X2A Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T383X2S Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T384X2A Poisoning by oral contraceptives, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T384X2S Poisoning by oral contraceptives, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T385X2A Poisoning by other estrogens and progestogens, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T385X2S Poisoning by other estrogens and progestogens, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T386X2A Poisoning by antigonadotrophins, antiestrogens, antiandrogens, not elsewhere classified, intentional 58 58 59 Yes Yes Yes No
self-harm, initial encounter

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 219 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T386X2S Poisoning by antigonadotrophins, antiestrogens, antiandrogens, not elsewhere classified, intentional 58 58 59 Yes Yes Yes No
self-harm, sequela
T387X2A Poisoning by androgens and anabolic congeners, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T387X2S Poisoning by androgens and anabolic congeners, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T38802A Poisoning by unspecified hormones and synthetic substitutes, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T38802S Poisoning by unspecified hormones and synthetic substitutes, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T38812A Poisoning by anterior pituitary [adenohypophyseal] hormones, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T38812S Poisoning by anterior pituitary [adenohypophyseal] hormones, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T38892A Poisoning by other hormones and synthetic substitutes, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T38892S Poisoning by other hormones and synthetic substitutes, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T38902A Poisoning by unspecified hormone antagonists, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T38902S Poisoning by unspecified hormone antagonists, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T38992A Poisoning by other hormone antagonists, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T38992S Poisoning by other hormone antagonists, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T39012A Poisoning by aspirin, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T39012S Poisoning by aspirin, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T39092A Poisoning by salicylates, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T39092S Poisoning by salicylates, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T391X2A Poisoning by 4-Aminophenol derivatives, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T391X2S Poisoning by 4-Aminophenol derivatives, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T392X2A Poisoning by pyrazolone derivatives, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T392X2S Poisoning by pyrazolone derivatives, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T39312A Poisoning by propionic acid derivatives, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T39312S Poisoning by propionic acid derivatives, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T39392A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T39392S Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T394X2A Poisoning by antirheumatics, not elsewhere classified, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T394X2S Poisoning by antirheumatics, not elsewhere classified, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T398X2A Poisoning by other nonopioid analgesics and antipyretics, not elsewhere classified, intentional self- 58 58 59 Yes Yes Yes No
harm, initial encounter
T398X2S Poisoning by other nonopioid analgesics and antipyretics, not elsewhere classified, intentional self- 58 58 59 Yes Yes Yes No
harm, sequela
T3992XA Poisoning by unspecified nonopioid analgesic, antipyretic and antirheumatic, intentional self-harm, 58 58 59 Yes Yes Yes No
initial encounter
T3992XS Poisoning by unspecified nonopioid analgesic, antipyretic and antirheumatic, intentional self-harm, 58 58 59 Yes Yes Yes No
sequela
T400X1A Poisoning by opium, accidental (unintentional), initial encounter 55 No No Yes No
T400X2A Poisoning by opium, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T400X2S Poisoning by opium, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T400X4A Poisoning by opium, undetermined, initial encounter 55 No No Yes No
T401X1A Poisoning by heroin, accidental (unintentional), initial encounter 55 No No Yes No
T401X2A Poisoning by heroin, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T401X2S Poisoning by heroin, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T401X4A Poisoning by heroin, undetermined, initial encounter 55 No No Yes No
T402X1A Poisoning by other opioids, accidental (unintentional), initial encounter 55 No No Yes No
T402X2A Poisoning by other opioids, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T402X2S Poisoning by other opioids, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T402X4A Poisoning by other opioids, undetermined, initial encounter 55 No No Yes No
T403X1A Poisoning by methadone, accidental (unintentional), initial encounter 55 No No Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 220 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T403X2A Poisoning by methadone, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T403X2S Poisoning by methadone, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T403X4A Poisoning by methadone, undetermined, initial encounter 55 No No Yes No
T40411A Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), initial encounter 55 No No Yes No
T40412A Poisoning by fentanyl or fentanyl analogs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T40412S Poisoning by fentanyl or fentanyl analogs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T40414A Poisoning by fentanyl or fentanyl analogs, undetermined, initial encounter 55 No No Yes No
T40421A Poisoning by tramadol, accidental (unintentional), initial encounter 55 No No Yes No
T40422A Poisoning by tramadol, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T40422S Poisoning by tramadol, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T40424A Poisoning by tramadol, undetermined, initial encounter 55 No No Yes No
T40491A Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter 55 No No Yes No
T40492A Poisoning by other synthetic narcotics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T40492S Poisoning by other synthetic narcotics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T40494A Poisoning by other synthetic narcotics, undetermined, initial encounter 55 No No Yes No
T404X1A Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter 55 No No Yes No
T404X2A Poisoning by other synthetic narcotics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T404X2S Poisoning by other synthetic narcotics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T404X4A Poisoning by other synthetic narcotics, undetermined, initial encounter 55 No No Yes No
T405X1A Poisoning by cocaine, accidental (unintentional), initial encounter 55 No No Yes No
T405X2A Poisoning by cocaine, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T405X2S Poisoning by cocaine, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T405X4A Poisoning by cocaine, undetermined, initial encounter 55 No No Yes No
T40601A Poisoning by unspecified narcotics, accidental (unintentional), initial encounter 55 No No Yes No
T40602A Poisoning by unspecified narcotics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T40602S Poisoning by unspecified narcotics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T40604A Poisoning by unspecified narcotics, undetermined, initial encounter 55 No No Yes No
T40691A Poisoning by other narcotics, accidental (unintentional), initial encounter 55 No No Yes No
T40692A Poisoning by other narcotics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T40692S Poisoning by other narcotics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T40694A Poisoning by other narcotics, undetermined, initial encounter 55 No No Yes No
T407X2A Poisoning by cannabis (derivatives), intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T407X2S Poisoning by cannabis (derivatives), intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T408X1A Poisoning by lysergide [LSD], accidental (unintentional), initial encounter 55 No No Yes No
T408X2A Poisoning by lysergide [LSD], intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T408X2S Poisoning by lysergide [LSD], intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T408X4A Poisoning by lysergide [LSD], undetermined, initial encounter 55 No No Yes No
T40901A Poisoning by unspecified psychodysleptics [hallucinogens], accidental (unintentional), initial 55 No No Yes No
encounter
T40902A Poisoning by unspecified psychodysleptics [hallucinogens], intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T40902S Poisoning by unspecified psychodysleptics [hallucinogens], intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T40904A Poisoning by unspecified psychodysleptics [hallucinogens], undetermined, initial encounter 55 No No Yes No
T40991A Poisoning by other psychodysleptics [hallucinogens], accidental (unintentional), initial encounter 55 No No Yes No
T40992A Poisoning by other psychodysleptics [hallucinogens], intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T40992S Poisoning by other psychodysleptics [hallucinogens], intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T40994A Poisoning by other psychodysleptics [hallucinogens], undetermined, initial encounter 55 No No Yes No
T410X2A Poisoning by inhaled anesthetics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T410X2S Poisoning by inhaled anesthetics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T411X2A Poisoning by intravenous anesthetics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T411X2S Poisoning by intravenous anesthetics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T41202A Poisoning by unspecified general anesthetics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 221 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T41202S Poisoning by unspecified general anesthetics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T41292A Poisoning by other general anesthetics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T41292S Poisoning by other general anesthetics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T413X2A Poisoning by local anesthetics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T413X2S Poisoning by local anesthetics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T4142XA Poisoning by unspecified anesthetic, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T4142XS Poisoning by unspecified anesthetic, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T415X2A Poisoning by therapeutic gases, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T415X2S Poisoning by therapeutic gases, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T420X2A Poisoning by hydantoin derivatives, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T420X2S Poisoning by hydantoin derivatives, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T421X2A Poisoning by iminostilbenes, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T421X2S Poisoning by iminostilbenes, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T422X2A Poisoning by succinimides and oxazolidinediones, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T422X2S Poisoning by succinimides and oxazolidinediones, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T423X2A Poisoning by barbiturates, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T423X2S Poisoning by barbiturates, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T424X2A Poisoning by benzodiazepines, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T424X2S Poisoning by benzodiazepines, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T425X2A Poisoning by mixed antiepileptics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T425X2S Poisoning by mixed antiepileptics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T426X2A Poisoning by other antiepileptic and sedative-hypnotic drugs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T426X2S Poisoning by other antiepileptic and sedative-hypnotic drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T4272XA Poisoning by unspecified antiepileptic and sedative-hypnotic drugs, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T4272XS Poisoning by unspecified antiepileptic and sedative-hypnotic drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T428X2A Poisoning by antiparkinsonism drugs and other central muscle-tone depressants, intentional self- 58 58 59 Yes Yes Yes No
harm, initial encounter
T428X2S Poisoning by antiparkinsonism drugs and other central muscle-tone depressants, intentional self- 58 58 59 Yes Yes Yes No
harm, sequela
T43012A Poisoning by tricyclic antidepressants, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T43012S Poisoning by tricyclic antidepressants, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T43022A Poisoning by tetracyclic antidepressants, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T43022S Poisoning by tetracyclic antidepressants, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T431X2A Poisoning by monoamine-oxidase-inhibitor antidepressants, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T431X2S Poisoning by monoamine-oxidase-inhibitor antidepressants, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T43202A Poisoning by unspecified antidepressants, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T43202S Poisoning by unspecified antidepressants, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T43212A Poisoning by selective serotonin and norepinephrine reuptake inhibitors, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T43212S Poisoning by selective serotonin and norepinephrine reuptake inhibitors, intentional self-harm, 58 58 59 Yes Yes Yes No
sequela
T43222A Poisoning by selective serotonin reuptake inhibitors, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T43222S Poisoning by selective serotonin reuptake inhibitors, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T43292A Poisoning by other antidepressants, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T43292S Poisoning by other antidepressants, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T433X2A Poisoning by phenothiazine antipsychotics and neuroleptics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T433X2S Poisoning by phenothiazine antipsychotics and neuroleptics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T434X2A Poisoning by butyrophenone and thiothixene neuroleptics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T434X2S Poisoning by butyrophenone and thiothixene neuroleptics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T43502A Poisoning by unspecified antipsychotics and neuroleptics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 222 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T43502S Poisoning by unspecified antipsychotics and neuroleptics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T43592A Poisoning by other antipsychotics and neuroleptics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T43592S Poisoning by other antipsychotics and neuroleptics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T43601A Poisoning by unspecified psychostimulants, accidental (unintentional), initial encounter 55 No No Yes No
T43602A Poisoning by unspecified psychostimulants, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T43602S Poisoning by unspecified psychostimulants, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T43604A Poisoning by unspecified psychostimulants, undetermined, initial encounter 55 No No Yes No
T43611A Poisoning by caffeine, accidental (unintentional), initial encounter 55 No No Yes No
T43612A Poisoning by caffeine, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T43612S Poisoning by caffeine, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T43614A Poisoning by caffeine, undetermined, initial encounter 55 No No Yes No
T43621A Poisoning by amphetamines, accidental (unintentional), initial encounter 55 No No Yes No
T43622A Poisoning by amphetamines, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T43622S Poisoning by amphetamines, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T43624A Poisoning by amphetamines, undetermined, initial encounter 55 No No Yes No
T43631A Poisoning by methylphenidate, accidental (unintentional), initial encounter 55 No No Yes No
T43632A Poisoning by methylphenidate, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T43632S Poisoning by methylphenidate, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T43634A Poisoning by methylphenidate, undetermined, initial encounter 55 No No Yes No
T43641A Poisoning by ecstasy, accidental (unintentional), initial encounter 55 No No Yes No
T43642A Poisoning by ecstasy, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T43642S Poisoning by ecstasy, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T43644A Poisoning by ecstasy, undetermined, initial encounter 55 No No Yes No
T43691A Poisoning by other psychostimulants, accidental (unintentional), initial encounter 55 No No Yes No
T43692A Poisoning by other psychostimulants, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T43692S Poisoning by other psychostimulants, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T43694A Poisoning by other psychostimulants, undetermined, initial encounter 55 No No Yes No
T438X2A Poisoning by other psychotropic drugs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T438X2S Poisoning by other psychotropic drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T4392XA Poisoning by unspecified psychotropic drug, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T4392XS Poisoning by unspecified psychotropic drug, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T440X2A Poisoning by anticholinesterase agents, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T440X2S Poisoning by anticholinesterase agents, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T441X2A Poisoning by other parasympathomimetics [cholinergics], intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T441X2S Poisoning by other parasympathomimetics [cholinergics], intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T442X2A Poisoning by ganglionic blocking drugs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T442X2S Poisoning by ganglionic blocking drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T443X2A Poisoning by other parasympatholytics [anticholinergics and antimuscarinics] and spasmolytics, 58 58 59 Yes Yes Yes No
intentional self-harm, initial encounter
T443X2S Poisoning by other parasympatholytics [anticholinergics and antimuscarinics] and spasmolytics, 58 58 59 Yes Yes Yes No
intentional self-harm, sequela
T444X2A Poisoning by predominantly alpha-adrenoreceptor agonists, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T444X2S Poisoning by predominantly alpha-adrenoreceptor agonists, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T445X2A Poisoning by predominantly beta-adrenoreceptor agonists, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T445X2S Poisoning by predominantly beta-adrenoreceptor agonists, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T446X2A Poisoning by alpha-adrenoreceptor antagonists, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T446X2S Poisoning by alpha-adrenoreceptor antagonists, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T447X2A Poisoning by beta-adrenoreceptor antagonists, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T447X2S Poisoning by beta-adrenoreceptor antagonists, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T448X2A Poisoning by centrally-acting and adrenergic-neuron-blocking agents, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 223 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T448X2S Poisoning by centrally-acting and adrenergic-neuron-blocking agents, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T44902A Poisoning by unspecified drugs primarily affecting the autonomic nervous system, intentional self- 58 58 59 Yes Yes Yes No
harm, initial encounter
T44902S Poisoning by unspecified drugs primarily affecting the autonomic nervous system, intentional self- 58 58 59 Yes Yes Yes No
harm, sequela
T44992A Poisoning by other drug primarily affecting the autonomic nervous system, intentional self-harm, 58 58 59 Yes Yes Yes No
initial encounter
T44992S Poisoning by other drug primarily affecting the autonomic nervous system, intentional self-harm, 58 58 59 Yes Yes Yes No
sequela
T450X2A Poisoning by antiallergic and antiemetic drugs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T450X2S Poisoning by antiallergic and antiemetic drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T451X2A Poisoning by antineoplastic and immunosuppressive drugs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T451X2S Poisoning by antineoplastic and immunosuppressive drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T452X2A Poisoning by vitamins, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T452X2S Poisoning by vitamins, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T453X2A Poisoning by enzymes, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T453X2S Poisoning by enzymes, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T454X2A Poisoning by iron and its compounds, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T454X2S Poisoning by iron and its compounds, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T45512A Poisoning by anticoagulants, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T45512S Poisoning by anticoagulants, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T45522A Poisoning by antithrombotic drugs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T45522S Poisoning by antithrombotic drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T45602A Poisoning by unspecified fibrinolysis-affecting drugs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T45602S Poisoning by unspecified fibrinolysis-affecting drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T45612A Poisoning by thrombolytic drug, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T45612S Poisoning by thrombolytic drug, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T45622A Poisoning by hemostatic drug, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T45622S Poisoning by hemostatic drug, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T45692A Poisoning by other fibrinolysis-affecting drugs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T45692S Poisoning by other fibrinolysis-affecting drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T457X2A Poisoning by anticoagulant antagonists, vitamin K and other coagulants, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T457X2S Poisoning by anticoagulant antagonists, vitamin K and other coagulants, intentional self-harm, 58 58 59 Yes Yes Yes No
sequela
T458X2A Poisoning by other primarily systemic and hematological agents, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T458X2S Poisoning by other primarily systemic and hematological agents, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T4592XA Poisoning by unspecified primarily systemic and hematological agent, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T4592XS Poisoning by unspecified primarily systemic and hematological agent, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T460X2A Poisoning by cardiac-stimulant glycosides and drugs of similar action, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T460X2S Poisoning by cardiac-stimulant glycosides and drugs of similar action, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T461X2A Poisoning by calcium-channel blockers, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T461X2S Poisoning by calcium-channel blockers, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T462X2A Poisoning by other antidysrhythmic drugs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T462X2S Poisoning by other antidysrhythmic drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T463X2A Poisoning by coronary vasodilators, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T463X2S Poisoning by coronary vasodilators, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T464X2A Poisoning by angiotensin-converting-enzyme inhibitors, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 224 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T464X2S Poisoning by angiotensin-converting-enzyme inhibitors, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T465X2A Poisoning by other antihypertensive drugs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T465X2S Poisoning by other antihypertensive drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T466X2A Poisoning by antihyperlipidemic and antiarteriosclerotic drugs, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T466X2S Poisoning by antihyperlipidemic and antiarteriosclerotic drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T467X2A Poisoning by peripheral vasodilators, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T467X2S Poisoning by peripheral vasodilators, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T468X2A Poisoning by antivaricose drugs, including sclerosing agents, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T468X2S Poisoning by antivaricose drugs, including sclerosing agents, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T46902A Poisoning by unspecified agents primarily affecting the cardiovascular system, intentional self-harm, 58 58 59 Yes Yes Yes No
initial encounter
T46902S Poisoning by unspecified agents primarily affecting the cardiovascular system, intentional self-harm, 58 58 59 Yes Yes Yes No
sequela
T46992A Poisoning by other agents primarily affecting the cardiovascular system, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T46992S Poisoning by other agents primarily affecting the cardiovascular system, intentional self-harm, 58 58 59 Yes Yes Yes No
sequela
T470X2A Poisoning by histamine H2-receptor blockers, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T470X2S Poisoning by histamine H2-receptor blockers, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T471X2A Poisoning by other antacids and anti-gastric-secretion drugs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T471X2S Poisoning by other antacids and anti-gastric-secretion drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T472X2A Poisoning by stimulant laxatives, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T472X2S Poisoning by stimulant laxatives, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T473X2A Poisoning by saline and osmotic laxatives, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T473X2S Poisoning by saline and osmotic laxatives, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T474X2A Poisoning by other laxatives, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T474X2S Poisoning by other laxatives, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T475X2A Poisoning by digestants, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T475X2S Poisoning by digestants, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T476X2A Poisoning by antidiarrheal drugs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T476X2S Poisoning by antidiarrheal drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T477X2A Poisoning by emetics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T477X2S Poisoning by emetics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T478X2A Poisoning by other agents primarily affecting gastrointestinal system, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T478X2S Poisoning by other agents primarily affecting gastrointestinal system, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T4792XA Poisoning by unspecified agents primarily affecting the gastrointestinal system, intentional self-harm, 58 58 59 Yes Yes Yes No
initial encounter
T4792XS Poisoning by unspecified agents primarily affecting the gastrointestinal system, intentional self-harm, 58 58 59 Yes Yes Yes No
sequela
T480X2A Poisoning by oxytocic drugs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T480X2S Poisoning by oxytocic drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T481X2A Poisoning by skeletal muscle relaxants [neuromuscular blocking agents], intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T481X2S Poisoning by skeletal muscle relaxants [neuromuscular blocking agents], intentional self-harm, 58 58 59 Yes Yes Yes No
sequela
T48202A Poisoning by unspecified drugs acting on muscles, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T48202S Poisoning by unspecified drugs acting on muscles, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T48292A Poisoning by other drugs acting on muscles, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T48292S Poisoning by other drugs acting on muscles, intentional self-harm, sequela 58 58 59 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 225 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T483X2A Poisoning by antitussives, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T483X2S Poisoning by antitussives, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T484X2A Poisoning by expectorants, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T484X2S Poisoning by expectorants, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T485X2A Poisoning by other anti-common-cold drugs, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T485X2S Poisoning by other anti-common-cold drugs, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T486X2A Poisoning by antiasthmatics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T486X2S Poisoning by antiasthmatics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T48902A Poisoning by unspecified agents primarily acting on the respiratory system, intentional self-harm, 58 58 59 Yes Yes Yes No
initial encounter
T48902S Poisoning by unspecified agents primarily acting on the respiratory system, intentional self-harm, 58 58 59 Yes Yes Yes No
sequela
T48992A Poisoning by other agents primarily acting on the respiratory system, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T48992S Poisoning by other agents primarily acting on the respiratory system, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T490X2A Poisoning by local antifungal, anti-infective and anti-inflammatory drugs, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T490X2S Poisoning by local antifungal, anti-infective and anti-inflammatory drugs, intentional self-harm, 58 58 59 Yes Yes Yes No
sequela
T491X2A Poisoning by antipruritics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T491X2S Poisoning by antipruritics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T492X2A Poisoning by local astringents and local detergents, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T492X2S Poisoning by local astringents and local detergents, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T493X2A Poisoning by emollients, demulcents and protectants, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T493X2S Poisoning by emollients, demulcents and protectants, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T494X2A Poisoning by keratolytics, keratoplastics, and other hair treatment drugs and preparations, 58 58 59 Yes Yes Yes No
intentional self-harm, initial encounter
T494X2S Poisoning by keratolytics, keratoplastics, and other hair treatment drugs and preparations, 58 58 59 Yes Yes Yes No
intentional self-harm, sequela
T495X2A Poisoning by ophthalmological drugs and preparations, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T495X2S Poisoning by ophthalmological drugs and preparations, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T496X2A Poisoning by otorhinolaryngological drugs and preparations, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T496X2S Poisoning by otorhinolaryngological drugs and preparations, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T497X2A Poisoning by dental drugs, topically applied, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T497X2S Poisoning by dental drugs, topically applied, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T498X2A Poisoning by other topical agents, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T498X2S Poisoning by other topical agents, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T4992XA Poisoning by unspecified topical agent, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T4992XS Poisoning by unspecified topical agent, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T500X2A Poisoning by mineralocorticoids and their antagonists, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T500X2S Poisoning by mineralocorticoids and their antagonists, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T501X2A Poisoning by loop [high-ceiling] diuretics, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T501X2S Poisoning by loop [high-ceiling] diuretics, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T502X2A Poisoning by carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, intentional self- 58 58 59 Yes Yes Yes No
harm, initial encounter
T502X2S Poisoning by carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, intentional self- 58 58 59 Yes Yes Yes No
harm, sequela
T503X2A Poisoning by electrolytic, caloric and water-balance agents, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T503X2S Poisoning by electrolytic, caloric and water-balance agents, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T504X2A Poisoning by drugs affecting uric acid metabolism, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T504X2S Poisoning by drugs affecting uric acid metabolism, intentional self-harm, sequela 58 58 59 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 226 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T505X2A Poisoning by appetite depressants, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T505X2S Poisoning by appetite depressants, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T506X2A Poisoning by antidotes and chelating agents, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T506X2S Poisoning by antidotes and chelating agents, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T507X2A Poisoning by analeptics and opioid receptor antagonists, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T507X2S Poisoning by analeptics and opioid receptor antagonists, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T508X2A Poisoning by diagnostic agents, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T508X2S Poisoning by diagnostic agents, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T50902A Poisoning by unspecified drugs, medicaments and biological substances, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T50902S Poisoning by unspecified drugs, medicaments and biological substances, intentional self-harm, 58 58 59 Yes Yes Yes No
sequela
T50912A Poisoning by multiple unspecified drugs, medicaments and biological substances, intentional self- 58 58 59 Yes Yes Yes No
harm, initial encounter
T50912S Poisoning by multiple unspecified drugs, medicaments and biological substances, intentional self- 58 58 59 Yes Yes Yes No
harm, sequela
T50992A Poisoning by other drugs, medicaments and biological substances, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T50992S Poisoning by other drugs, medicaments and biological substances, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T50A12A Poisoning by pertussis vaccine, including combinations with a pertussis component, intentional self- 58 58 59 Yes Yes Yes No
harm, initial encounter
T50A12S Poisoning by pertussis vaccine, including combinations with a pertussis component, intentional self- 58 58 59 Yes Yes Yes No
harm, sequela
T50A22A Poisoning by mixed bacterial vaccines without a pertussis component, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T50A22S Poisoning by mixed bacterial vaccines without a pertussis component, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T50A92A Poisoning by other bacterial vaccines, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T50A92S Poisoning by other bacterial vaccines, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T50B12A Poisoning by smallpox vaccines, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T50B12S Poisoning by smallpox vaccines, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T50B92A Poisoning by other viral vaccines, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T50B92S Poisoning by other viral vaccines, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T50Z12A Poisoning by immunoglobulin, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T50Z12S Poisoning by immunoglobulin, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T50Z92A Poisoning by other vaccines and biological substances, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T50Z92S Poisoning by other vaccines and biological substances, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T510X1A Toxic effect of ethanol, accidental (unintentional), initial encounter 55 No No Yes No
T510X2A Toxic effect of ethanol, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T510X2S Toxic effect of ethanol, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T510X4A Toxic effect of ethanol, undetermined, initial encounter 55 No No Yes No
T511X2A Toxic effect of methanol, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T511X2S Toxic effect of methanol, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T512X2A Toxic effect of 2-Propanol, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T512X2S Toxic effect of 2-Propanol, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T513X2A Toxic effect of fusel oil, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T513X2S Toxic effect of fusel oil, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T518X2A Toxic effect of other alcohols, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T518X2S Toxic effect of other alcohols, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T5192XA Toxic effect of unspecified alcohol, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T5192XS Toxic effect of unspecified alcohol, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T520X2A Toxic effect of petroleum products, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 227 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T520X2S Toxic effect of petroleum products, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T521X2A Toxic effect of benzene, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T521X2S Toxic effect of benzene, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T522X2A Toxic effect of homologues of benzene, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T522X2S Toxic effect of homologues of benzene, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T523X2A Toxic effect of glycols, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T523X2S Toxic effect of glycols, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T524X2A Toxic effect of ketones, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T524X2S Toxic effect of ketones, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T528X2A Toxic effect of other organic solvents, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T528X2S Toxic effect of other organic solvents, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T5292XA Toxic effect of unspecified organic solvent, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T5292XS Toxic effect of unspecified organic solvent, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T530X2A Toxic effect of carbon tetrachloride, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T530X2S Toxic effect of carbon tetrachloride, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T531X2A Toxic effect of chloroform, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T531X2S Toxic effect of chloroform, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T532X2A Toxic effect of trichloroethylene, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T532X2S Toxic effect of trichloroethylene, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T533X2A Toxic effect of tetrachloroethylene, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T533X2S Toxic effect of tetrachloroethylene, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T534X2A Toxic effect of dichloromethane, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T534X2S Toxic effect of dichloromethane, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T535X2A Toxic effect of chlorofluorocarbons, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T535X2S Toxic effect of chlorofluorocarbons, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T536X2A Toxic effect of other halogen derivatives of aliphatic hydrocarbons, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T536X2S Toxic effect of other halogen derivatives of aliphatic hydrocarbons, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T537X2A Toxic effect of other halogen derivatives of aromatic hydrocarbons, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T537X2S Toxic effect of other halogen derivatives of aromatic hydrocarbons, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T5392XA Toxic effect of unspecified halogen derivatives of aliphatic and aromatic hydrocarbons, intentional 58 58 59 Yes Yes Yes No
self-harm, initial encounter
T5392XS Toxic effect of unspecified halogen derivatives of aliphatic and aromatic hydrocarbons, intentional 58 58 59 Yes Yes Yes No
self-harm, sequela
T540X2A Toxic effect of phenol and phenol homologues, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T540X2S Toxic effect of phenol and phenol homologues, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T541X2A Toxic effect of other corrosive organic compounds, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T541X2S Toxic effect of other corrosive organic compounds, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T542X2A Toxic effect of corrosive acids and acid-like substances, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T542X2S Toxic effect of corrosive acids and acid-like substances, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T543X2A Toxic effect of corrosive alkalis and alkali-like substances, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T543X2S Toxic effect of corrosive alkalis and alkali-like substances, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T5492XA Toxic effect of unspecified corrosive substance, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T5492XS Toxic effect of unspecified corrosive substance, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T550X2A Toxic effect of soaps, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T550X2S Toxic effect of soaps, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T551X2A Toxic effect of detergents, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T551X2S Toxic effect of detergents, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T560X2A Toxic effect of lead and its compounds, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T560X2S Toxic effect of lead and its compounds, intentional self-harm, sequela 58 58 59 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 228 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T561X2A Toxic effect of mercury and its compounds, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T561X2S Toxic effect of mercury and its compounds, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T562X2A Toxic effect of chromium and its compounds, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T562X2S Toxic effect of chromium and its compounds, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T563X2A Toxic effect of cadmium and its compounds, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T563X2S Toxic effect of cadmium and its compounds, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T564X2A Toxic effect of copper and its compounds, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T564X2S Toxic effect of copper and its compounds, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T565X2A Toxic effect of zinc and its compounds, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T565X2S Toxic effect of zinc and its compounds, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T566X2A Toxic effect of tin and its compounds, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T566X2S Toxic effect of tin and its compounds, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T567X2A Toxic effect of beryllium and its compounds, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T567X2S Toxic effect of beryllium and its compounds, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T56812A Toxic effect of thallium, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T56812S Toxic effect of thallium, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T56892A Toxic effect of other metals, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T56892S Toxic effect of other metals, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T5692XA Toxic effect of unspecified metal, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T5692XS Toxic effect of unspecified metal, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T570X2A Toxic effect of arsenic and its compounds, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T570X2S Toxic effect of arsenic and its compounds, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T571X2A Toxic effect of phosphorus and its compounds, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T571X2S Toxic effect of phosphorus and its compounds, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T572X2A Toxic effect of manganese and its compounds, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T572X2S Toxic effect of manganese and its compounds, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T573X2A Toxic effect of hydrogen cyanide, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T573X2S Toxic effect of hydrogen cyanide, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T578X2A Toxic effect of other specified inorganic substances, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T578X2S Toxic effect of other specified inorganic substances, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T5792XA Toxic effect of unspecified inorganic substance, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T5792XS Toxic effect of unspecified inorganic substance, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T5802XA Toxic effect of carbon monoxide from motor vehicle exhaust, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T5802XS Toxic effect of carbon monoxide from motor vehicle exhaust, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T5812XA Toxic effect of carbon monoxide from utility gas, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T5812XS Toxic effect of carbon monoxide from utility gas, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T582X2A Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, intentional 58 58 59 Yes Yes Yes No
self-harm, initial encounter
T582X2S Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, intentional 58 58 59 Yes Yes Yes No
self-harm, sequela
T588X2A Toxic effect of carbon monoxide from other source, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T588X2S Toxic effect of carbon monoxide from other source, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T5892XA Toxic effect of carbon monoxide from unspecified source, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T5892XS Toxic effect of carbon monoxide from unspecified source, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T590X2A Toxic effect of nitrogen oxides, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T590X2S Toxic effect of nitrogen oxides, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T591X2A Toxic effect of sulfur dioxide, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T591X2S Toxic effect of sulfur dioxide, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T592X2A Toxic effect of formaldehyde, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T592X2S Toxic effect of formaldehyde, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T593X2A Toxic effect of lacrimogenic gas, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 229 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T593X2S Toxic effect of lacrimogenic gas, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T594X2A Toxic effect of chlorine gas, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T594X2S Toxic effect of chlorine gas, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T595X2A Toxic effect of fluorine gas and hydrogen fluoride, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T595X2S Toxic effect of fluorine gas and hydrogen fluoride, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T596X2A Toxic effect of hydrogen sulfide, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T596X2S Toxic effect of hydrogen sulfide, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T597X2A Toxic effect of carbon dioxide, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T597X2S Toxic effect of carbon dioxide, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T59812A Toxic effect of smoke, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T59812S Toxic effect of smoke, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T59892A Toxic effect of other specified gases, fumes and vapors, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T59892S Toxic effect of other specified gases, fumes and vapors, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T5992XA Toxic effect of unspecified gases, fumes and vapors, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T5992XS Toxic effect of unspecified gases, fumes and vapors, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T600X2A Toxic effect of organophosphate and carbamate insecticides, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T600X2S Toxic effect of organophosphate and carbamate insecticides, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T601X2A Toxic effect of halogenated insecticides, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T601X2S Toxic effect of halogenated insecticides, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T602X2A Toxic effect of other insecticides, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T602X2S Toxic effect of other insecticides, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T603X2A Toxic effect of herbicides and fungicides, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T603X2S Toxic effect of herbicides and fungicides, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T604X2A Toxic effect of rodenticides, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T604X2S Toxic effect of rodenticides, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T608X2A Toxic effect of other pesticides, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T608X2S Toxic effect of other pesticides, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T6092XA Toxic effect of unspecified pesticide, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T6092XS Toxic effect of unspecified pesticide, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T6102XA Ciguatera fish poisoning, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T6102XS Ciguatera fish poisoning, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T6112XA Scombroid fish poisoning, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T6112XS Scombroid fish poisoning, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T61772A Other fish poisoning, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T61772S Other fish poisoning, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T61782A Other shellfish poisoning, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T61782S Other shellfish poisoning, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T618X2A Toxic effect of other seafood, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T618X2S Toxic effect of other seafood, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T6192XA Toxic effect of unspecified seafood, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T6192XS Toxic effect of unspecified seafood, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T620X2A Toxic effect of ingested mushrooms, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T620X2S Toxic effect of ingested mushrooms, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T621X2A Toxic effect of ingested berries, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T621X2S Toxic effect of ingested berries, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T622X2A Toxic effect of other ingested (parts of) plant(s), intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T622X2S Toxic effect of other ingested (parts of) plant(s), intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T628X2A Toxic effect of other specified noxious substances eaten as food, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T628X2S Toxic effect of other specified noxious substances eaten as food, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T6292XA Toxic effect of unspecified noxious substance eaten as food, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 230 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T6292XS Toxic effect of unspecified noxious substance eaten as food, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63002A Toxic effect of unspecified snake venom, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63002S Toxic effect of unspecified snake venom, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63012A Toxic effect of rattlesnake venom, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63012S Toxic effect of rattlesnake venom, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63022A Toxic effect of coral snake venom, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63022S Toxic effect of coral snake venom, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63032A Toxic effect of taipan venom, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63032S Toxic effect of taipan venom, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63042A Toxic effect of cobra venom, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63042S Toxic effect of cobra venom, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63062A Toxic effect of venom of other North and South American snake, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T63062S Toxic effect of venom of other North and South American snake, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63072A Toxic effect of venom of other Australian snake, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63072S Toxic effect of venom of other Australian snake, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63082A Toxic effect of venom of other African and Asian snake, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63082S Toxic effect of venom of other African and Asian snake, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63092A Toxic effect of venom of other snake, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63092S Toxic effect of venom of other snake, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63112A Toxic effect of venom of gila monster, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63112S Toxic effect of venom of gila monster, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63122A Toxic effect of venom of other venomous lizard, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63122S Toxic effect of venom of other venomous lizard, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63192A Toxic effect of venom of other reptiles, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63192S Toxic effect of venom of other reptiles, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T632X2A Toxic effect of venom of scorpion, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T632X2S Toxic effect of venom of scorpion, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63302A Toxic effect of unspecified spider venom, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63302S Toxic effect of unspecified spider venom, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63312A Toxic effect of venom of black widow spider, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63312S Toxic effect of venom of black widow spider, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63322A Toxic effect of venom of tarantula, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63322S Toxic effect of venom of tarantula, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63332A Toxic effect of venom of brown recluse spider, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63332S Toxic effect of venom of brown recluse spider, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63392A Toxic effect of venom of other spider, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63392S Toxic effect of venom of other spider, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63412A Toxic effect of venom of centipedes and venomous millipedes, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T63412S Toxic effect of venom of centipedes and venomous millipedes, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63422A Toxic effect of venom of ants, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63422S Toxic effect of venom of ants, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63432A Toxic effect of venom of caterpillars, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63432S Toxic effect of venom of caterpillars, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63442A Toxic effect of venom of bees, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63442S Toxic effect of venom of bees, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63452A Toxic effect of venom of hornets, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63452S Toxic effect of venom of hornets, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63462A Toxic effect of venom of wasps, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63462S Toxic effect of venom of wasps, intentional self-harm, sequela 58 58 59 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 231 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T63482A Toxic effect of venom of other arthropod, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63482S Toxic effect of venom of other arthropod, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63512A Toxic effect of contact with stingray, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63512S Toxic effect of contact with stingray, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63592A Toxic effect of contact with other venomous fish, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63592S Toxic effect of contact with other venomous fish, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63612A Toxic effect of contact with Portugese Man-o-war, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63612S Toxic effect of contact with Portugese Man-o-war, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63622A Toxic effect of contact with other jellyfish, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63622S Toxic effect of contact with other jellyfish, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63632A Toxic effect of contact with sea anemone, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63632S Toxic effect of contact with sea anemone, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63692A Toxic effect of contact with other venomous marine animals, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63692S Toxic effect of contact with other venomous marine animals, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63712A Toxic effect of contact with venomous marine plant, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63712S Toxic effect of contact with venomous marine plant, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63792A Toxic effect of contact with other venomous plant, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63792S Toxic effect of contact with other venomous plant, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63812A Toxic effect of contact with venomous frog, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63812S Toxic effect of contact with venomous frog, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63822A Toxic effect of contact with venomous toad, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63822S Toxic effect of contact with venomous toad, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63832A Toxic effect of contact with other venomous amphibian, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63832S Toxic effect of contact with other venomous amphibian, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T63892A Toxic effect of contact with other venomous animals, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T63892S Toxic effect of contact with other venomous animals, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T6392XA Toxic effect of contact with unspecified venomous animal, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T6392XS Toxic effect of contact with unspecified venomous animal, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T6402XA Toxic effect of aflatoxin, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T6402XS Toxic effect of aflatoxin, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T6482XA Toxic effect of other mycotoxin food contaminants, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T6482XS Toxic effect of other mycotoxin food contaminants, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T650X2A Toxic effect of cyanides, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T650X2S Toxic effect of cyanides, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T651X2A Toxic effect of strychnine and its salts, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T651X2S Toxic effect of strychnine and its salts, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T65212A Toxic effect of chewing tobacco, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T65212S Toxic effect of chewing tobacco, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T65222A Toxic effect of tobacco cigarettes, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T65222S Toxic effect of tobacco cigarettes, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T65292A Toxic effect of other tobacco and nicotine, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T65292S Toxic effect of other tobacco and nicotine, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T653X2A Toxic effect of nitroderivatives and aminoderivatives of benzene and its homologues, intentional self- 58 58 59 Yes Yes Yes No
harm, initial encounter
T653X2S Toxic effect of nitroderivatives and aminoderivatives of benzene and its homologues, intentional self- 58 58 59 Yes Yes Yes No
harm, sequela
T654X2A Toxic effect of carbon disulfide, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T654X2S Toxic effect of carbon disulfide, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T655X2A Toxic effect of nitroglycerin and other nitric acids and esters, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T655X2S Toxic effect of nitroglycerin and other nitric acids and esters, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T656X2A Toxic effect of paints and dyes, not elsewhere classified, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 232 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T656X2S Toxic effect of paints and dyes, not elsewhere classified, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T65812A Toxic effect of latex, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T65812S Toxic effect of latex, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T65822A Toxic effect of harmful algae and algae toxins, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T65822S Toxic effect of harmful algae and algae toxins, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T65832A Toxic effect of fiberglass, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T65832S Toxic effect of fiberglass, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T65892A Toxic effect of other specified substances, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T65892S Toxic effect of other specified substances, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T6592XA Toxic effect of unspecified substance, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T6592XS Toxic effect of unspecified substance, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T71112A Asphyxiation due to smothering under pillow, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T71112S Asphyxiation due to smothering under pillow, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T71122A Asphyxiation due to plastic bag, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T71122S Asphyxiation due to plastic bag, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T71132A Asphyxiation due to being trapped in bed linens, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T71132S Asphyxiation due to being trapped in bed linens, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T71152A Asphyxiation due to smothering in furniture, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T71152S Asphyxiation due to smothering in furniture, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T71162A Asphyxiation due to hanging, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T71162S Asphyxiation due to hanging, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T71192A Asphyxiation due to mechanical threat to breathing due to other causes, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T71192S Asphyxiation due to mechanical threat to breathing due to other causes, intentional self-harm, 58 58 59 Yes Yes Yes No
sequela
T71222A Asphyxiation due to being trapped in a car trunk, intentional self-harm, initial encounter 58 58 59 Yes Yes Yes No
T71222S Asphyxiation due to being trapped in a car trunk, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T71232A Asphyxiation due to being trapped in a (discarded) refrigerator, intentional self-harm, initial 58 58 59 Yes Yes Yes No
encounter
T71232S Asphyxiation due to being trapped in a (discarded) refrigerator, intentional self-harm, sequela 58 58 59 Yes Yes Yes No
T790XXA Air embolism (traumatic), initial encounter 173 173 173 Yes Yes Yes No
T791XXA Fat embolism (traumatic), initial encounter 173 173 173 Yes Yes Yes No
T792XXA Traumatic secondary and recurrent hemorrhage and seroma, initial encounter 173 173 173 Yes Yes Yes No
T794XXA Traumatic shock, initial encounter 173 173 173 Yes Yes Yes No
T795XXA Traumatic anuria, initial encounter 173 173 173 Yes Yes Yes No
T796XXA Traumatic ischemia of muscle, initial encounter 173 173 173 Yes Yes Yes No
T797XXA Traumatic subcutaneous emphysema, initial encounter 173 173 173 Yes Yes Yes No
T798XXA Other early complications of trauma, initial encounter 173 173 173 Yes Yes Yes No
T799XXA Unspecified early complication of trauma, initial encounter 173 173 173 Yes Yes Yes No
T79A0XA Compartment syndrome, unspecified, initial encounter 173 173 173 Yes Yes Yes No
T79A11A Traumatic compartment syndrome of right upper extremity, initial encounter 173 173 173 Yes Yes Yes No
T79A12A Traumatic compartment syndrome of left upper extremity, initial encounter 173 173 173 Yes Yes Yes No
T79A19A Traumatic compartment syndrome of unspecified upper extremity, initial encounter 173 173 173 Yes Yes Yes No
T79A21A Traumatic compartment syndrome of right lower extremity, initial encounter 173 173 173 Yes Yes Yes No
T79A22A Traumatic compartment syndrome of left lower extremity, initial encounter 173 173 173 Yes Yes Yes No
T79A29A Traumatic compartment syndrome of unspecified lower extremity, initial encounter 173 173 173 Yes Yes Yes No
T79A3XA Traumatic compartment syndrome of abdomen, initial encounter 173 173 173 Yes Yes Yes No
T79A9XA Traumatic compartment syndrome of other sites, initial encounter 173 173 173 Yes Yes Yes No
T8111XA Postprocedural cardiogenic shock, initial encounter 84 84 84 Yes Yes Yes No
T8112XA Postprocedural septic shock, initial encounter 2 2 2 Yes Yes Yes No
T8144XA Sepsis following a procedure, initial encounter 2 2 2 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 233 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T81502A Unspecified complication of foreign body accidentally left in body following kidney dialysis, initial 134 134 134 261 Yes Yes Yes Yes
encounter
T81502D Unspecified complication of foreign body accidentally left in body following kidney dialysis, 134 134 134 261 Yes Yes Yes Yes
subsequent encounter
T81502S Unspecified complication of foreign body accidentally left in body following kidney dialysis, sequela 134 134 134 261 Yes Yes Yes Yes
T81512A Adhesions due to foreign body accidentally left in body following kidney dialysis, initial encounter 134 134 134 261 Yes Yes Yes Yes
T81512D Adhesions due to foreign body accidentally left in body following kidney dialysis, subsequent 134 134 134 261 Yes Yes Yes Yes
encounter
T81512S Adhesions due to foreign body accidentally left in body following kidney dialysis, sequela 134 134 134 261 Yes Yes Yes Yes
T81522A Obstruction due to foreign body accidentally left in body following kidney dialysis, initial encounter 134 134 134 261 Yes Yes Yes Yes
T81522D Obstruction due to foreign body accidentally left in body following kidney dialysis, subsequent 134 134 134 261 Yes Yes Yes Yes
encounter
T81522S Obstruction due to foreign body accidentally left in body following kidney dialysis, sequela 134 134 134 261 Yes Yes Yes Yes
T81532A Perforation due to foreign body accidentally left in body following kidney dialysis, initial encounter 134 134 134 261 Yes Yes Yes Yes
T81532D Perforation due to foreign body accidentally left in body following kidney dialysis, subsequent 134 134 134 261 Yes Yes Yes Yes
encounter
T81532S Perforation due to foreign body accidentally left in body following kidney dialysis, sequela 134 134 134 261 Yes Yes Yes Yes
T81592A Other complications of foreign body accidentally left in body following kidney dialysis, initial 134 134 134 261 Yes Yes Yes Yes
encounter
T81592D Other complications of foreign body accidentally left in body following kidney dialysis, subsequent 134 134 134 261 Yes Yes Yes Yes
encounter
T81592S Other complications of foreign body accidentally left in body following kidney dialysis, sequela 134 134 134 261 Yes Yes Yes Yes
T82310A Breakdown (mechanical) of aortic (bifurcation) graft (replacement), initial encounter 176 176 176 Yes Yes Yes No
T82311A Breakdown (mechanical) of carotid arterial graft (bypass), initial encounter 176 176 176 Yes Yes Yes No
T82312A Breakdown (mechanical) of femoral arterial graft (bypass), initial encounter 176 176 176 Yes Yes Yes No
T82318A Breakdown (mechanical) of other vascular grafts, initial encounter 176 176 176 Yes Yes Yes No
T82319A Breakdown (mechanical) of unspecified vascular grafts, initial encounter 176 176 176 Yes Yes Yes No
T82320A Displacement of aortic (bifurcation) graft (replacement), initial encounter 176 176 176 Yes Yes Yes No
T82321A Displacement of carotid arterial graft (bypass), initial encounter 176 176 176 Yes Yes Yes No
T82322A Displacement of femoral arterial graft (bypass), initial encounter 176 176 176 Yes Yes Yes No
T82328A Displacement of other vascular grafts, initial encounter 176 176 176 Yes Yes Yes No
T82329A Displacement of unspecified vascular grafts, initial encounter 176 176 176 Yes Yes Yes No
T82330A Leakage of aortic (bifurcation) graft (replacement), initial encounter 176 176 176 Yes Yes Yes No
T82331A Leakage of carotid arterial graft (bypass), initial encounter 176 176 176 Yes Yes Yes No
T82332A Leakage of femoral arterial graft (bypass), initial encounter 176 176 176 Yes Yes Yes No
T82338A Leakage of other vascular grafts, initial encounter 176 176 176 Yes Yes Yes No
T82339A Leakage of unspecified vascular graft, initial encounter 176 176 176 Yes Yes Yes No
T82390A Other mechanical complication of aortic (bifurcation) graft (replacement), initial encounter 176 176 176 Yes Yes Yes No
T82391A Other mechanical complication of carotid arterial graft (bypass), initial encounter 176 176 176 Yes Yes Yes No
T82392A Other mechanical complication of femoral arterial graft (bypass), initial encounter 176 176 176 Yes Yes Yes No
T82398A Other mechanical complication of other vascular grafts, initial encounter 176 176 176 Yes Yes Yes No
T82399A Other mechanical complication of unspecified vascular grafts, initial encounter 176 176 176 Yes Yes Yes No
T8241XA Breakdown (mechanical) of vascular dialysis catheter, initial encounter 134 134 134 261 Yes Yes Yes Yes
T8241XD Breakdown (mechanical) of vascular dialysis catheter, subsequent encounter 134 134 134 261 Yes Yes Yes Yes
T8241XS Breakdown (mechanical) of vascular dialysis catheter, sequela 134 134 134 261 Yes Yes Yes Yes
T8242XA Displacement of vascular dialysis catheter, initial encounter 134 134 134 261 Yes Yes Yes Yes
T8242XD Displacement of vascular dialysis catheter, subsequent encounter 134 134 134 261 Yes Yes Yes Yes
T8242XS Displacement of vascular dialysis catheter, sequela 134 134 134 261 Yes Yes Yes Yes
T8243XA Leakage of vascular dialysis catheter, initial encounter 134 134 134 261 Yes Yes Yes Yes
T8243XD Leakage of vascular dialysis catheter, subsequent encounter 134 134 134 261 Yes Yes Yes Yes
T8243XS Leakage of vascular dialysis catheter, sequela 134 134 134 261 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 234 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T8249XA Other complication of vascular dialysis catheter, initial encounter 134 134 134 261 Yes Yes Yes Yes
T8249XD Other complication of vascular dialysis catheter, subsequent encounter 134 134 134 261 Yes Yes Yes Yes
T8249XS Other complication of vascular dialysis catheter, sequela 134 134 134 261 Yes Yes Yes Yes
T82510A Breakdown (mechanical) of surgically created arteriovenous fistula, initial encounter 176 176 176 Yes Yes Yes No
T82511A Breakdown (mechanical) of surgically created arteriovenous shunt, initial encounter 176 176 176 Yes Yes Yes No
T82513A Breakdown (mechanical) of balloon (counterpulsation) device, initial encounter 176 176 176 Yes Yes Yes No
T82514A Breakdown (mechanical) of infusion catheter, initial encounter 176 176 176 Yes Yes Yes No
T82515A Breakdown (mechanical) of umbrella device, initial encounter 176 176 176 Yes Yes Yes No
T82518A Breakdown (mechanical) of other cardiac and vascular devices and implants, initial encounter 176 176 176 Yes Yes Yes No
T82520A Displacement of surgically created arteriovenous fistula, initial encounter 176 176 176 Yes Yes Yes No
T82521A Displacement of surgically created arteriovenous shunt, initial encounter 176 176 176 Yes Yes Yes No
T82523A Displacement of balloon (counterpulsation) device, initial encounter 176 176 176 Yes Yes Yes No
T82524A Displacement of infusion catheter, initial encounter 176 176 176 Yes Yes Yes No
T82525A Displacement of umbrella device, initial encounter 176 176 176 Yes Yes Yes No
T82528A Displacement of other cardiac and vascular devices and implants, initial encounter 176 176 176 Yes Yes Yes No
T82530A Leakage of surgically created arteriovenous fistula, initial encounter 176 176 176 Yes Yes Yes No
T82531A Leakage of surgically created arteriovenous shunt, initial encounter 176 176 176 Yes Yes Yes No
T82533A Leakage of balloon (counterpulsation) device, initial encounter 176 176 176 Yes Yes Yes No
T82534A Leakage of infusion catheter, initial encounter 176 176 176 Yes Yes Yes No
T82535A Leakage of umbrella device, initial encounter 176 176 176 Yes Yes Yes No
T82538A Leakage of other cardiac and vascular devices and implants, initial encounter 176 176 176 Yes Yes Yes No
T82590A Other mechanical complication of surgically created arteriovenous fistula, initial encounter 176 176 176 Yes Yes Yes No
T82591A Other mechanical complication of surgically created arteriovenous shunt, initial encounter 176 176 176 Yes Yes Yes No
T82593A Other mechanical complication of balloon (counterpulsation) device, initial encounter 176 176 176 Yes Yes Yes No
T82594A Other mechanical complication of infusion catheter, initial encounter 176 176 176 Yes Yes Yes No
T82595A Other mechanical complication of umbrella device, initial encounter 176 176 176 Yes Yes Yes No
T82598A Other mechanical complication of other cardiac and vascular devices and implants, initial encounter 176 176 176 Yes Yes Yes No
T826XXA Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T827XXA Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, 176 176 176 Yes Yes Yes No
initial encounter
T82818A Embolism due to vascular prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T82828A Fibrosis due to vascular prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T82838A Hemorrhage due to vascular prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T82848A Pain due to vascular prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T82856A Stenosis of peripheral vascular stent, initial encounter 176 176 176 Yes Yes Yes No
T82858A Stenosis of other vascular prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T82868A Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T82898A Other specified complication of vascular prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T83010A Breakdown (mechanical) of cystostomy catheter, initial encounter 176 176 176 Yes Yes Yes No
T83011A Breakdown (mechanical) of indwelling urethral catheter, initial encounter 176 176 176 Yes Yes Yes No
T83012A Breakdown (mechanical) of nephrostomy catheter, initial encounter 176 176 176 Yes Yes Yes No
T83018A Breakdown (mechanical) of other urinary catheter, initial encounter 176 176 176 Yes Yes Yes No
T83020A Displacement of cystostomy catheter, initial encounter 176 176 176 Yes Yes Yes No
T83021A Displacement of indwelling urethral catheter, initial encounter 176 176 176 Yes Yes Yes No
T83022A Displacement of nephrostomy catheter, initial encounter 176 176 176 Yes Yes Yes No
T83028A Displacement of other urinary catheter, initial encounter 176 176 176 Yes Yes Yes No
T83030A Leakage of cystostomy catheter, initial encounter 176 176 176 Yes Yes Yes No
T83031A Leakage of indwelling urethral catheter, initial encounter 176 176 176 Yes Yes Yes No
T83032A Leakage of nephrostomy catheter, initial encounter 176 176 176 Yes Yes Yes No
T83038A Leakage of other urinary catheter, initial encounter 176 176 176 Yes Yes Yes No
T83090A Other mechanical complication of cystostomy catheter, initial encounter 176 176 176 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 235 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T83091A Other mechanical complication of indwelling urethral catheter, initial encounter 176 176 176 Yes Yes Yes No
T83092A Other mechanical complication of nephrostomy catheter, initial encounter 176 176 176 Yes Yes Yes No
T83098A Other mechanical complication of other urinary catheter, initial encounter 176 176 176 Yes Yes Yes No
T83110A Breakdown (mechanical) of urinary electronic stimulator device, initial encounter 176 176 176 Yes Yes Yes No
T83111A Breakdown (mechanical) of implanted urinary sphincter, initial encounter 176 176 176 Yes Yes Yes No
T83112A Breakdown (mechanical) of indwelling ureteral stent, initial encounter 176 176 176 Yes Yes Yes No
T83113A Breakdown (mechanical) of other urinary stents, initial encounter 176 176 176 Yes Yes Yes No
T83118A Breakdown (mechanical) of other urinary devices and implants, initial encounter 176 176 176 Yes Yes Yes No
T83120A Displacement of urinary electronic stimulator device, initial encounter 176 176 176 Yes Yes Yes No
T83121A Displacement of implanted urinary sphincter, initial encounter 176 176 176 Yes Yes Yes No
T83122A Displacement of indwelling ureteral stent, initial encounter 176 176 176 Yes Yes Yes No
T83123A Displacement of other urinary stents, initial encounter 176 176 176 Yes Yes Yes No
T83128A Displacement of other urinary devices and implants, initial encounter 176 176 176 Yes Yes Yes No
T83190A Other mechanical complication of urinary electronic stimulator device, initial encounter 176 176 176 Yes Yes Yes No
T83191A Other mechanical complication of implanted urinary sphincter, initial encounter 176 176 176 Yes Yes Yes No
T83192A Other mechanical complication of indwelling ureteral stent, initial encounter 176 176 176 Yes Yes Yes No
T83193A Other mechanical complication of other urinary stent, initial encounter 176 176 176 Yes Yes Yes No
T83198A Other mechanical complication of other urinary devices and implants, initial encounter 176 176 176 Yes Yes Yes No
T8321XA Breakdown (mechanical) of graft of urinary organ, initial encounter 176 176 176 Yes Yes Yes No
T8322XA Displacement of graft of urinary organ, initial encounter 176 176 176 Yes Yes Yes No
T8323XA Leakage of graft of urinary organ, initial encounter 176 176 176 Yes Yes Yes No
T8324XA Erosion of graft of urinary organ, initial encounter 176 176 176 Yes Yes Yes No
T8325XA Exposure of graft of urinary organ, initial encounter 176 176 176 Yes Yes Yes No
T8329XA Other mechanical complication of graft of urinary organ, initial encounter 176 176 176 Yes Yes Yes No
T83410A Breakdown (mechanical) of implanted penile prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T83411A Breakdown (mechanical) of implanted testicular prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T83418A Breakdown (mechanical) of other prosthetic devices, implants and grafts of genital tract, initial 176 176 176 Yes Yes Yes No
encounter
T83420A Displacement of implanted penile prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T83421A Displacement of implanted testicular prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T83428A Displacement of other prosthetic devices, implants and grafts of genital tract, initial encounter 176 176 176 Yes Yes Yes No
T83490A Other mechanical complication of implanted penile prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T83491A Other mechanical complication of implanted testicular prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T83498A Other mechanical complication of other prosthetic devices, implants and grafts of genital tract, initial 176 176 176 Yes Yes Yes No
encounter
T83510A Infection and inflammatory reaction due to cystostomy catheter, initial encounter 176 176 176 Yes Yes Yes No
T83511A Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter 176 176 176 Yes Yes Yes No
T83512A Infection and inflammatory reaction due to nephrostomy catheter, initial encounter 176 176 176 Yes Yes Yes No
T83518A Infection and inflammatory reaction due to other urinary catheter, initial encounter 176 176 176 Yes Yes Yes No
T83590A Infection and inflammatory reaction due to implanted urinary neurostimulation device, initial 176 176 176 Yes Yes Yes No
encounter
T83591A Infection and inflammatory reaction due to implanted urinary sphincter, initial encounter 176 176 176 Yes Yes Yes No
T83592A Infection and inflammatory reaction due to indwelling ureteral stent, initial encounter 176 176 176 Yes Yes Yes No
T83593A Infection and inflammatory reaction due to other urinary stents, initial encounter 176 176 176 Yes Yes Yes No
T83598A Infection and inflammatory reaction due to other prosthetic device, implant and graft in urinary 176 176 176 Yes Yes Yes No
system, initial encounter
T8361XA Infection and inflammatory reaction due to implanted penile prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T8362XA Infection and inflammatory reaction due to implanted testicular prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T8369XA Infection and inflammatory reaction due to other prosthetic device, implant and graft in genital tract, 176 176 176 Yes Yes Yes No
initial encounter
T83711A Erosion of implanted vaginal mesh to surrounding organ or tissue, initial encounter 176 176 176 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 236 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T83712A Erosion of implanted urethral mesh to surrounding organ or tissue, initial encounter 176 176 176 Yes Yes Yes No
T83713A Erosion of implanted urethral bulking agent to surrounding organ or tissue, initial encounter 176 176 176 Yes Yes Yes No
T83714A Erosion of implanted ureteral bulking agent to surrounding organ or tissue, initial encounter 176 176 176 Yes Yes Yes No
T83718A Erosion of other implanted mesh to organ or tissue, initial encounter 176 176 176 Yes Yes Yes No
T83719A Erosion of other prosthetic materials to surrounding organ or tissue, initial encounter 176 176 176 Yes Yes Yes No
T83721A Exposure of implanted vaginal mesh into vagina, initial encounter 176 176 176 Yes Yes Yes No
T83722A Exposure of implanted urethral mesh into urethra, initial encounter 176 176 176 Yes Yes Yes No
T83723A Exposure of implanted urethral bulking agent into urethra, initial encounter 176 176 176 Yes Yes Yes No
T83724A Exposure of implanted ureteral bulking agent into ureter, initial encounter 176 176 176 Yes Yes Yes No
T83728A Exposure of other implanted mesh into organ or tissue, initial encounter 176 176 176 Yes Yes Yes No
T83729A Exposure of other prosthetic materials into organ or tissue, initial encounter 176 176 176 Yes Yes Yes No
T8379XA Other specified complications due to other genitourinary prosthetic materials, initial encounter 176 176 176 Yes Yes Yes No
T8381XA Embolism due to genitourinary prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T8382XA Fibrosis due to genitourinary prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T8383XA Hemorrhage due to genitourinary prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T8384XA Pain due to genitourinary prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T8385XA Stenosis due to genitourinary prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T8386XA Thrombosis due to genitourinary prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T8389XA Other specified complication of genitourinary prosthetic devices, implants and grafts, initial 176 176 176 Yes Yes Yes No
encounter
T839XXA Unspecified complication of genitourinary prosthetic device, implant and graft, initial encounter 176 176 176 Yes Yes Yes No
T84010A Broken internal right hip prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T84011A Broken internal left hip prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T84012A Broken internal right knee prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T84013A Broken internal left knee prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T84018A Broken internal joint prosthesis, other site, initial encounter 176 176 176 Yes Yes Yes No
T84019A Broken internal joint prosthesis, unspecified site, initial encounter 176 176 176 Yes Yes Yes No
T84020A Dislocation of internal right hip prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T84021A Dislocation of internal left hip prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T84022A Instability of internal right knee prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T84023A Instability of internal left knee prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T84028A Dislocation of other internal joint prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T84029A Dislocation of unspecified internal joint prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T84030A Mechanical loosening of internal right hip prosthetic joint, initial encounter 176 176 176 Yes Yes Yes No
T84031A Mechanical loosening of internal left hip prosthetic joint, initial encounter 176 176 176 Yes Yes Yes No
T84032A Mechanical loosening of internal right knee prosthetic joint, initial encounter 176 176 176 Yes Yes Yes No
T84033A Mechanical loosening of internal left knee prosthetic joint, initial encounter 176 176 176 Yes Yes Yes No
T84038A Mechanical loosening of other internal prosthetic joint, initial encounter 176 176 176 Yes Yes Yes No
T84039A Mechanical loosening of unspecified internal prosthetic joint, initial encounter 176 176 176 Yes Yes Yes No
T84050A Periprosthetic osteolysis of internal prosthetic right hip joint, initial encounter 176 176 176 Yes Yes Yes No
T84051A Periprosthetic osteolysis of internal prosthetic left hip joint, initial encounter 176 176 176 Yes Yes Yes No
T84052A Periprosthetic osteolysis of internal prosthetic right knee joint, initial encounter 176 176 176 Yes Yes Yes No
T84053A Periprosthetic osteolysis of internal prosthetic left knee joint, initial encounter 176 176 176 Yes Yes Yes No
T84058A Periprosthetic osteolysis of other internal prosthetic joint, initial encounter 176 176 176 Yes Yes Yes No
T84059A Periprosthetic osteolysis of unspecified internal prosthetic joint, initial encounter 176 176 176 Yes Yes Yes No
T84060A Wear of articular bearing surface of internal prosthetic right hip joint, initial encounter 176 176 176 Yes Yes Yes No
T84061A Wear of articular bearing surface of internal prosthetic left hip joint, initial encounter 176 176 176 Yes Yes Yes No
T84062A Wear of articular bearing surface of internal prosthetic right knee joint, initial encounter 176 176 176 Yes Yes Yes No
T84063A Wear of articular bearing surface of internal prosthetic left knee joint, initial encounter 176 176 176 Yes Yes Yes No
T84068A Wear of articular bearing surface of other internal prosthetic joint, initial encounter 176 176 176 Yes Yes Yes No
T84069A Wear of articular bearing surface of unspecified internal prosthetic joint, initial encounter 176 176 176 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 237 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T84090A Other mechanical complication of internal right hip prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T84091A Other mechanical complication of internal left hip prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T84092A Other mechanical complication of internal right knee prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T84093A Other mechanical complication of internal left knee prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T84098A Other mechanical complication of other internal joint prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T84099A Other mechanical complication of unspecified internal joint prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T84110A Breakdown (mechanical) of internal fixation device of right humerus, initial encounter 176 176 176 Yes Yes Yes No
T84111A Breakdown (mechanical) of internal fixation device of left humerus, initial encounter 176 176 176 Yes Yes Yes No
T84112A Breakdown (mechanical) of internal fixation device of bone of right forearm, initial encounter 176 176 176 Yes Yes Yes No
T84113A Breakdown (mechanical) of internal fixation device of bone of left forearm, initial encounter 176 176 176 Yes Yes Yes No
T84114A Breakdown (mechanical) of internal fixation device of right femur, initial encounter 176 176 176 Yes Yes Yes No
T84115A Breakdown (mechanical) of internal fixation device of left femur, initial encounter 176 176 176 Yes Yes Yes No
T84116A Breakdown (mechanical) of internal fixation device of bone of right lower leg, initial encounter 176 176 176 Yes Yes Yes No
T84117A Breakdown (mechanical) of internal fixation device of bone of left lower leg, initial encounter 176 176 176 Yes Yes Yes No
T84119A Breakdown (mechanical) of internal fixation device of unspecified bone of limb, initial encounter 176 176 176 Yes Yes Yes No
T84120A Displacement of internal fixation device of right humerus, initial encounter 176 176 176 Yes Yes Yes No
T84121A Displacement of internal fixation device of left humerus, initial encounter 176 176 176 Yes Yes Yes No
T84122A Displacement of internal fixation device of bone of right forearm, initial encounter 176 176 176 Yes Yes Yes No
T84123A Displacement of internal fixation device of bone of left forearm, initial encounter 176 176 176 Yes Yes Yes No
T84124A Displacement of internal fixation device of right femur, initial encounter 176 176 176 Yes Yes Yes No
T84125A Displacement of internal fixation device of left femur, initial encounter 176 176 176 Yes Yes Yes No
T84126A Displacement of internal fixation device of bone of right lower leg, initial encounter 176 176 176 Yes Yes Yes No
T84127A Displacement of internal fixation device of bone of left lower leg, initial encounter 176 176 176 Yes Yes Yes No
T84129A Displacement of internal fixation device of unspecified bone of limb, initial encounter 176 176 176 Yes Yes Yes No
T84190A Other mechanical complication of internal fixation device of right humerus, initial encounter 176 176 176 Yes Yes Yes No
T84191A Other mechanical complication of internal fixation device of left humerus, initial encounter 176 176 176 Yes Yes Yes No
T84192A Other mechanical complication of internal fixation device of bone of right forearm, initial encounter 176 176 176 Yes Yes Yes No
T84193A Other mechanical complication of internal fixation device of bone of left forearm, initial encounter 176 176 176 Yes Yes Yes No
T84194A Other mechanical complication of internal fixation device of right femur, initial encounter 176 176 176 Yes Yes Yes No
T84195A Other mechanical complication of internal fixation device of left femur, initial encounter 176 176 176 Yes Yes Yes No
T84196A Other mechanical complication of internal fixation device of bone of right lower leg, initial encounter 176 176 176 Yes Yes Yes No
T84197A Other mechanical complication of internal fixation device of bone of left lower leg, initial encounter 176 176 176 Yes Yes Yes No
T84199A Other mechanical complication of internal fixation device of unspecified bone of limb, initial 176 176 176 Yes Yes Yes No
encounter
T84210A Breakdown (mechanical) of internal fixation device of bones of hand and fingers, initial encounter 176 176 176 Yes Yes Yes No
T84213A Breakdown (mechanical) of internal fixation device of bones of foot and toes, initial encounter 176 176 176 Yes Yes Yes No
T84216A Breakdown (mechanical) of internal fixation device of vertebrae, initial encounter 176 176 176 Yes Yes Yes No
T84218A Breakdown (mechanical) of internal fixation device of other bones, initial encounter 176 176 176 Yes Yes Yes No
T84220A Displacement of internal fixation device of bones of hand and fingers, initial encounter 176 176 176 Yes Yes Yes No
T84223A Displacement of internal fixation device of bones of foot and toes, initial encounter 176 176 176 Yes Yes Yes No
T84226A Displacement of internal fixation device of vertebrae, initial encounter 176 176 176 Yes Yes Yes No
T84228A Displacement of internal fixation device of other bones, initial encounter 176 176 176 Yes Yes Yes No
T84290A Other mechanical complication of internal fixation device of bones of hand and fingers, initial 176 176 176 Yes Yes Yes No
encounter
T84293A Other mechanical complication of internal fixation device of bones of foot and toes, initial encounter 176 176 176 Yes Yes Yes No
T84296A Other mechanical complication of internal fixation device of vertebrae, initial encounter 176 176 176 Yes Yes Yes No
T84298A Other mechanical complication of internal fixation device of other bones, initial encounter 176 176 176 Yes Yes Yes No
T84310A Breakdown (mechanical) of electronic bone stimulator, initial encounter 176 176 176 Yes Yes Yes No
T84318A Breakdown (mechanical) of other bone devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T84320A Displacement of electronic bone stimulator, initial encounter 176 176 176 Yes Yes Yes No
T84328A Displacement of other bone devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 238 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T84390A Other mechanical complication of electronic bone stimulator, initial encounter 176 176 176 Yes Yes Yes No
T84398A Other mechanical complication of other bone devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T84410A Breakdown (mechanical) of muscle and tendon graft, initial encounter 176 176 176 Yes Yes Yes No
T84418A Breakdown (mechanical) of other internal orthopedic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T84420A Displacement of muscle and tendon graft, initial encounter 176 176 176 Yes Yes Yes No
T84428A Displacement of other internal orthopedic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T84490A Other mechanical complication of muscle and tendon graft, initial encounter 176 176 176 Yes Yes Yes No
T84498A Other mechanical complication of other internal orthopedic devices, implants and grafts, initial 176 176 176 Yes Yes Yes No
encounter
T8450XA Infection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T8451XA Infection and inflammatory reaction due to internal right hip prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T8452XA Infection and inflammatory reaction due to internal left hip prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T8453XA Infection and inflammatory reaction due to internal right knee prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T8454XA Infection and inflammatory reaction due to internal left knee prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T8459XA Infection and inflammatory reaction due to other internal joint prosthesis, initial encounter 176 176 176 Yes Yes Yes No
T8460XA Infection and inflammatory reaction due to internal fixation device of unspecified site, initial 176 176 176 Yes Yes Yes No
encounter
T84610A Infection and inflammatory reaction due to internal fixation device of right humerus, initial 176 176 176 Yes Yes Yes No
encounter
T84611A Infection and inflammatory reaction due to internal fixation device of left humerus, initial encounter 176 176 176 Yes Yes Yes No
T84612A Infection and inflammatory reaction due to internal fixation device of right radius, initial encounter 176 176 176 Yes Yes Yes No
T84613A Infection and inflammatory reaction due to internal fixation device of left radius, initial encounter 176 176 176 Yes Yes Yes No
T84614A Infection and inflammatory reaction due to internal fixation device of right ulna, initial encounter 176 176 176 Yes Yes Yes No
T84615A Infection and inflammatory reaction due to internal fixation device of left ulna, initial encounter 176 176 176 Yes Yes Yes No
T84619A Infection and inflammatory reaction due to internal fixation device of unspecified bone of arm, initial 176 176 176 Yes Yes Yes No
encounter
T84620A Infection and inflammatory reaction due to internal fixation device of right femur, initial encounter 176 176 176 Yes Yes Yes No
T84621A Infection and inflammatory reaction due to internal fixation device of left femur, initial encounter 176 176 176 Yes Yes Yes No
T84622A Infection and inflammatory reaction due to internal fixation device of right tibia, initial encounter 176 176 176 Yes Yes Yes No
T84623A Infection and inflammatory reaction due to internal fixation device of left tibia, initial encounter 176 176 176 Yes Yes Yes No
T84624A Infection and inflammatory reaction due to internal fixation device of right fibula, initial encounter 176 176 176 Yes Yes Yes No
T84625A Infection and inflammatory reaction due to internal fixation device of left fibula, initial encounter 176 176 176 Yes Yes Yes No
T84629A Infection and inflammatory reaction due to internal fixation device of unspecified bone of leg, initial 176 176 176 Yes Yes Yes No
encounter
T8463XA Infection and inflammatory reaction due to internal fixation device of spine, initial encounter 176 176 176 Yes Yes Yes No
T8469XA Infection and inflammatory reaction due to internal fixation device of other site, initial encounter 176 176 176 Yes Yes Yes No
T847XXA Infection and inflammatory reaction due to other internal orthopedic prosthetic devices, implants 176 176 176 Yes Yes Yes No
and grafts, initial encounter
T8481XA Embolism due to internal orthopedic prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T8482XA Fibrosis due to internal orthopedic prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T8483XA Hemorrhage due to internal orthopedic prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T8484XA Pain due to internal orthopedic prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T8485XA Stenosis due to internal orthopedic prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T8486XA Thrombosis due to internal orthopedic prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T8489XA Other specified complication of internal orthopedic prosthetic devices, implants and grafts, initial 176 176 176 Yes Yes Yes No
encounter
T849XXA Unspecified complication of internal orthopedic prosthetic device, implant and graft, initial 176 176 176 Yes Yes Yes No
encounter
T8501XA Breakdown (mechanical) of ventricular intracranial (communicating) shunt, initial encounter 176 176 176 Yes Yes Yes No
T8502XA Displacement of ventricular intracranial (communicating) shunt, initial encounter 176 176 176 Yes Yes Yes No
T8503XA Leakage of ventricular intracranial (communicating) shunt, initial encounter 176 176 176 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 239 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T8509XA Other mechanical complication of ventricular intracranial (communicating) shunt, initial encounter 176 176 176 Yes Yes Yes No
T85110A Breakdown (mechanical) of implanted electronic neurostimulator of brain electrode (lead), initial 176 176 176 Yes Yes Yes No
encounter
T85111A Breakdown (mechanical) of implanted electronic neurostimulator of peripheral nerve electrode 176 176 176 Yes Yes Yes No
(lead), initial encounter
T85112A Breakdown (mechanical) of implanted electronic neurostimulator of spinal cord electrode (lead), 176 176 176 Yes Yes Yes No
initial encounter
T85113A Breakdown (mechanical) of implanted electronic neurostimulator, generator, initial encounter 176 176 176 Yes Yes Yes No
T85118A Breakdown (mechanical) of other implanted electronic stimulator of nervous system, initial 176 176 176 Yes Yes Yes No
encounter
T85120A Displacement of implanted electronic neurostimulator of brain electrode (lead), initial encounter 176 176 176 Yes Yes Yes No
T85121A Displacement of implanted electronic neurostimulator of peripheral nerve electrode (lead), initial 176 176 176 Yes Yes Yes No
encounter
T85122A Displacement of implanted electronic neurostimulator of spinal cord electrode (lead), initial 176 176 176 Yes Yes Yes No
encounter
T85123A Displacement of implanted electronic neurostimulator, generator, initial encounter 176 176 176 Yes Yes Yes No
T85128A Displacement of other implanted electronic stimulator of nervous system, initial encounter 176 176 176 Yes Yes Yes No
T85190A Other mechanical complication of implanted electronic neurostimulator of brain electrode (lead), 176 176 176 Yes Yes Yes No
initial encounter
T85191A Other mechanical complication of implanted electronic neurostimulator of peripheral nerve 176 176 176 Yes Yes Yes No
electrode (lead), initial encounter
T85192A Other mechanical complication of implanted electronic neurostimulator of spinal cord electrode 176 176 176 Yes Yes Yes No
(lead), initial encounter
T85193A Other mechanical complication of implanted electronic neurostimulator, generator, initial encounter 176 176 176 Yes Yes Yes No
T85199A Other mechanical complication of other implanted electronic stimulator of nervous system, initial 176 176 176 Yes Yes Yes No
encounter
T85611A Breakdown (mechanical) of intraperitoneal dialysis catheter, initial encounter 134 134 134 261 Yes Yes Yes Yes
T85611D Breakdown (mechanical) of intraperitoneal dialysis catheter, subsequent encounter 134 134 134 261 Yes Yes Yes Yes
T85611S Breakdown (mechanical) of intraperitoneal dialysis catheter, sequela 134 134 134 261 Yes Yes Yes Yes
T85615A Breakdown (mechanical) of other nervous system device, implant or graft, initial encounter 176 176 176 Yes Yes Yes No
T85621A Displacement of intraperitoneal dialysis catheter, initial encounter 134 134 134 261 Yes Yes Yes Yes
T85621D Displacement of intraperitoneal dialysis catheter, subsequent encounter 134 134 134 261 Yes Yes Yes Yes
T85621S Displacement of intraperitoneal dialysis catheter, sequela 134 134 134 261 Yes Yes Yes Yes
T85625A Displacement of other nervous system device, implant or graft, initial encounter 176 176 176 Yes Yes Yes No
T85631A Leakage of intraperitoneal dialysis catheter, initial encounter 134 134 134 261 Yes Yes Yes Yes
T85631D Leakage of intraperitoneal dialysis catheter, subsequent encounter 134 134 134 261 Yes Yes Yes Yes
T85631S Leakage of intraperitoneal dialysis catheter, sequela 134 134 134 261 Yes Yes Yes Yes
T85635A Leakage of other nervous system device, implant or graft, initial encounter 176 176 176 Yes Yes Yes No
T85691A Other mechanical complication of intraperitoneal dialysis catheter, initial encounter 134 134 134 261 Yes Yes Yes Yes
T85691D Other mechanical complication of intraperitoneal dialysis catheter, subsequent encounter 134 134 134 261 Yes Yes Yes Yes
T85691S Other mechanical complication of intraperitoneal dialysis catheter, sequela 134 134 134 261 Yes Yes Yes Yes
T85695A Other mechanical complication of other nervous system device, implant or graft, initial encounter 176 176 176 Yes Yes Yes No
T8571XA Infection and inflammatory reaction due to peritoneal dialysis catheter, initial encounter 134 134 134 261 Yes Yes Yes Yes
T8571XD Infection and inflammatory reaction due to peritoneal dialysis catheter, subsequent encounter 134 134 134 261 Yes Yes Yes Yes
T8571XS Infection and inflammatory reaction due to peritoneal dialysis catheter, sequela 134 134 134 261 Yes Yes Yes Yes
T8572XA Infection and inflammatory reaction due to insulin pump, initial encounter 176 176 176 Yes Yes Yes No
T85730A Infection and inflammatory reaction due to ventricular intracranial (communicating) shunt, initial 176 176 176 Yes Yes Yes No
encounter
T85731A Infection and inflammatory reaction due to implanted electronic neurostimulator of brain, electrode 176 176 176 Yes Yes Yes No
(lead), initial encounter

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 240 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T85732A Infection and inflammatory reaction due to implanted electronic neurostimulator of peripheral 176 176 176 Yes Yes Yes No
nerve, electrode (lead), initial encounter
T85733A Infection and inflammatory reaction due to implanted electronic neurostimulator of spinal cord, 176 176 176 Yes Yes Yes No
electrode (lead), initial encounter
T85734A Infection and inflammatory reaction due to implanted electronic neurostimulator, generator, initial 176 176 176 Yes Yes Yes No
encounter
T85735A Infection and inflammatory reaction due to cranial or spinal infusion catheter, initial encounter 176 176 176 Yes Yes Yes No
T85738A Infection and inflammatory reaction due to other nervous system device, implant or graft, initial 176 176 176 Yes Yes Yes No
encounter
T8579XA Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, 176 176 176 Yes Yes Yes No
initial encounter
T85810A Embolism due to nervous system prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T85820A Fibrosis due to nervous system prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T85830A Hemorrhage due to nervous system prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T85840A Pain due to nervous system prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T85850A Stenosis due to nervous system prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T85860A Thrombosis due to nervous system prosthetic devices, implants and grafts, initial encounter 176 176 176 Yes Yes Yes No
T85890A Other specified complication of nervous system prosthetic devices, implants and grafts, initial 176 176 176 Yes Yes Yes No
encounter
T8600 Unspecified complication of bone marrow transplant 186 186 186 396 Yes Yes Yes Yes
T8601 Bone marrow transplant rejection 186 186 186 396 Yes Yes Yes Yes
T8602 Bone marrow transplant failure 186 186 186 396 Yes Yes Yes Yes
T8603 Bone marrow transplant infection 186 186 186 396 Yes Yes Yes Yes
T8609 Other complications of bone marrow transplant 186 186 186 396 Yes Yes Yes Yes
T8610 Unspecified complication of kidney transplant 260 No No No Yes
T8611 Kidney transplant rejection 260 No No No Yes
T8612 Kidney transplant failure 260 No No No Yes
T8613 Kidney transplant infection 260 No No No Yes
T8619 Other complication of kidney transplant 260 No No No Yes
T8620 Unspecified complication of heart transplant 186 186 186 396 Yes Yes Yes Yes
T8621 Heart transplant rejection 186 186 186 396 Yes Yes Yes Yes
T8622 Heart transplant failure 186 186 186 396 Yes Yes Yes Yes
T8623 Heart transplant infection 186 186 186 396 Yes Yes Yes Yes
T86290 Cardiac allograft vasculopathy 186 186 186 396 Yes Yes Yes Yes
T86298 Other complications of heart transplant 186 186 186 396 Yes Yes Yes Yes
T8630 Unspecified complication of heart-lung transplant 186 186 186 395 Yes Yes Yes Yes
T8630 Unspecified complication of heart-lung transplant 396 -- -- -- Yes
T8631 Heart-lung transplant rejection 186 186 186 395 Yes Yes Yes Yes
T8631 Heart-lung transplant rejection 396 -- -- -- Yes
T8632 Heart-lung transplant failure 186 186 186 395 Yes Yes Yes Yes
T8632 Heart-lung transplant failure 396 -- -- -- Yes
T8633 Heart-lung transplant infection 186 186 186 395 Yes Yes Yes Yes
T8633 Heart-lung transplant infection 396 -- -- -- Yes
T8639 Other complications of heart-lung transplant 186 186 186 395 Yes Yes Yes Yes
T8639 Other complications of heart-lung transplant 396 -- -- -- Yes
T8640 Unspecified complication of liver transplant 186 186 186 396 Yes Yes Yes Yes
T8641 Liver transplant rejection 186 186 186 396 Yes Yes Yes Yes
T8642 Liver transplant failure 186 186 186 396 Yes Yes Yes Yes
T8643 Liver transplant infection 186 186 186 396 Yes Yes Yes Yes
T8649 Other complications of liver transplant 186 186 186 396 Yes Yes Yes Yes
T865 Complications of stem cell transplant 186 186 186 396 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 241 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

T86810 Lung transplant rejection 186 186 186 395 Yes Yes Yes Yes
T86811 Lung transplant failure 186 186 186 395 Yes Yes Yes Yes
T86812 Lung transplant infection 186 186 186 395 Yes Yes Yes Yes
T86818 Other complications of lung transplant 186 186 186 395 Yes Yes Yes Yes
T86819 Unspecified complication of lung transplant 186 186 186 395 Yes Yes Yes Yes
T86842 Corneal transplant infection 176 176 176 Yes Yes Yes No
T868421 Corneal transplant infection, right eye 176 176 176 Yes Yes Yes No
T868422 Corneal transplant infection, left eye 176 176 176 Yes Yes Yes No
T868423 Corneal transplant infection, bilateral 176 176 176 Yes Yes Yes No
T868429 Corneal transplant infection, unspecified eye 176 176 176 Yes Yes Yes No
T86850 Intestine transplant rejection 186 186 186 396 Yes Yes Yes Yes
T86851 Intestine transplant failure 186 186 186 396 Yes Yes Yes Yes
T86852 Intestine transplant infection 186 186 186 396 Yes Yes Yes Yes
T86858 Other complications of intestine transplant 186 186 186 396 Yes Yes Yes Yes
T86859 Unspecified complication of intestine transplant 186 186 186 396 Yes Yes Yes Yes
T870X1 Complications of reattached (part of) right upper extremity 173 173 173 Yes Yes Yes No
T870X2 Complications of reattached (part of) left upper extremity 173 173 173 Yes Yes Yes No
T870X9 Complications of reattached (part of) unspecified upper extremity 173 173 173 Yes Yes Yes No
T871X1 Complications of reattached (part of) right lower extremity 173 173 173 Yes Yes Yes No
T871X2 Complications of reattached (part of) left lower extremity 173 173 173 Yes Yes Yes No
T871X9 Complications of reattached (part of) unspecified lower extremity 173 173 173 Yes Yes Yes No
T872 Complications of other reattached body part 173 173 173 Yes Yes Yes No
T8730 Neuroma of amputation stump, unspecified extremity 189 189 189 Yes Yes Yes No
T8731 Neuroma of amputation stump, right upper extremity 189 189 189 Yes Yes Yes No
T8732 Neuroma of amputation stump, left upper extremity 189 189 189 Yes Yes Yes No
T8733 Neuroma of amputation stump, right lower extremity 189 189 189 Yes Yes Yes No
T8734 Neuroma of amputation stump, left lower extremity 189 189 189 Yes Yes Yes No
T8740 Infection of amputation stump, unspecified extremity 189 189 189 Yes Yes Yes No
T8741 Infection of amputation stump, right upper extremity 189 189 189 Yes Yes Yes No
T8742 Infection of amputation stump, left upper extremity 189 189 189 Yes Yes Yes No
T8743 Infection of amputation stump, right lower extremity 189 189 189 Yes Yes Yes No
T8744 Infection of amputation stump, left lower extremity 189 189 189 Yes Yes Yes No
T8750 Necrosis of amputation stump, unspecified extremity 189 189 189 Yes Yes Yes No
T8751 Necrosis of amputation stump, right upper extremity 189 189 189 Yes Yes Yes No
T8752 Necrosis of amputation stump, left upper extremity 189 189 189 Yes Yes Yes No
T8753 Necrosis of amputation stump, right lower extremity 189 189 189 Yes Yes Yes No
T8754 Necrosis of amputation stump, left lower extremity 189 189 189 Yes Yes Yes No
T8781 Dehiscence of amputation stump 189 189 189 Yes Yes Yes No
T8789 Other complications of amputation stump 189 189 189 Yes Yes Yes No
T879 Unspecified complications of amputation stump 189 189 189 Yes Yes Yes No
X710XXA Intentional self-harm by drowning and submersion while in bathtub, initial encounter 58 58 59 Yes Yes Yes No
X710XXD Intentional self-harm by drowning and submersion while in bathtub, subsequent encounter 58 58 59 Yes Yes Yes No
X710XXS Intentional self-harm by drowning and submersion while in bathtub, sequela 58 58 59 Yes Yes Yes No
X711XXA Intentional self-harm by drowning and submersion while in swimming pool, initial encounter 58 58 59 Yes Yes Yes No
X711XXD Intentional self-harm by drowning and submersion while in swimming pool, subsequent encounter 58 58 59 Yes Yes Yes No
X711XXS Intentional self-harm by drowning and submersion while in swimming pool, sequela 58 58 59 Yes Yes Yes No
X712XXA Intentional self-harm by drowning and submersion after jump into swimming pool, initial encounter 58 58 59 Yes Yes Yes No
X712XXD Intentional self-harm by drowning and submersion after jump into swimming pool, subsequent 58 58 59 Yes Yes Yes No
encounter
X712XXS Intentional self-harm by drowning and submersion after jump into swimming pool, sequela 58 58 59 Yes Yes Yes No
X713XXA Intentional self-harm by drowning and submersion in natural water, initial encounter 58 58 59 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 242 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

X713XXD Intentional self-harm by drowning and submersion in natural water, subsequent encounter 58 58 59 Yes Yes Yes No
X713XXS Intentional self-harm by drowning and submersion in natural water, sequela 58 58 59 Yes Yes Yes No
X718XXA Other intentional self-harm by drowning and submersion, initial encounter 58 58 59 Yes Yes Yes No
X718XXD Other intentional self-harm by drowning and submersion, subsequent encounter 58 58 59 Yes Yes Yes No
X718XXS Other intentional self-harm by drowning and submersion, sequela 58 58 59 Yes Yes Yes No
X719XXA Intentional self-harm by drowning and submersion, unspecified, initial encounter 58 58 59 Yes Yes Yes No
X719XXD Intentional self-harm by drowning and submersion, unspecified, subsequent encounter 58 58 59 Yes Yes Yes No
X719XXS Intentional self-harm by drowning and submersion, unspecified, sequela 58 58 59 Yes Yes Yes No
X72XXXA Intentional self-harm by handgun discharge, initial encounter 58 58 59 Yes Yes Yes No
X72XXXD Intentional self-harm by handgun discharge, subsequent encounter 58 58 59 Yes Yes Yes No
X72XXXS Intentional self-harm by handgun discharge, sequela 58 58 59 Yes Yes Yes No
X730XXA Intentional self-harm by shotgun discharge, initial encounter 58 58 59 Yes Yes Yes No
X730XXD Intentional self-harm by shotgun discharge, subsequent encounter 58 58 59 Yes Yes Yes No
X730XXS Intentional self-harm by shotgun discharge, sequela 58 58 59 Yes Yes Yes No
X731XXA Intentional self-harm by hunting rifle discharge, initial encounter 58 58 59 Yes Yes Yes No
X731XXD Intentional self-harm by hunting rifle discharge, subsequent encounter 58 58 59 Yes Yes Yes No
X731XXS Intentional self-harm by hunting rifle discharge, sequela 58 58 59 Yes Yes Yes No
X732XXA Intentional self-harm by machine gun discharge, initial encounter 58 58 59 Yes Yes Yes No
X732XXD Intentional self-harm by machine gun discharge, subsequent encounter 58 58 59 Yes Yes Yes No
X732XXS Intentional self-harm by machine gun discharge, sequela 58 58 59 Yes Yes Yes No
X738XXA Intentional self-harm by other larger firearm discharge, initial encounter 58 58 59 Yes Yes Yes No
X738XXD Intentional self-harm by other larger firearm discharge, subsequent encounter 58 58 59 Yes Yes Yes No
X738XXS Intentional self-harm by other larger firearm discharge, sequela 58 58 59 Yes Yes Yes No
X739XXA Intentional self-harm by unspecified larger firearm discharge, initial encounter 58 58 59 Yes Yes Yes No
X739XXD Intentional self-harm by unspecified larger firearm discharge, subsequent encounter 58 58 59 Yes Yes Yes No
X739XXS Intentional self-harm by unspecified larger firearm discharge, sequela 58 58 59 Yes Yes Yes No
X7401XA Intentional self-harm by airgun, initial encounter 58 58 59 Yes Yes Yes No
X7401XD Intentional self-harm by airgun, subsequent encounter 58 58 59 Yes Yes Yes No
X7401XS Intentional self-harm by airgun, sequela 58 58 59 Yes Yes Yes No
X7402XA Intentional self-harm by paintball gun, initial encounter 58 58 59 Yes Yes Yes No
X7402XD Intentional self-harm by paintball gun, subsequent encounter 58 58 59 Yes Yes Yes No
X7402XS Intentional self-harm by paintball gun, sequela 58 58 59 Yes Yes Yes No
X7409XA Intentional self-harm by other gas, air or spring-operated gun, initial encounter 58 58 59 Yes Yes Yes No
X7409XD Intentional self-harm by other gas, air or spring-operated gun, subsequent encounter 58 58 59 Yes Yes Yes No
X7409XS Intentional self-harm by other gas, air or spring-operated gun, sequela 58 58 59 Yes Yes Yes No
X748XXA Intentional self-harm by other firearm discharge, initial encounter 58 58 59 Yes Yes Yes No
X748XXD Intentional self-harm by other firearm discharge, subsequent encounter 58 58 59 Yes Yes Yes No
X748XXS Intentional self-harm by other firearm discharge, sequela 58 58 59 Yes Yes Yes No
X749XXA Intentional self-harm by unspecified firearm discharge, initial encounter 58 58 59 Yes Yes Yes No
X749XXD Intentional self-harm by unspecified firearm discharge, subsequent encounter 58 58 59 Yes Yes Yes No
X749XXS Intentional self-harm by unspecified firearm discharge, sequela 58 58 59 Yes Yes Yes No
X75XXXA Intentional self-harm by explosive material, initial encounter 58 58 59 Yes Yes Yes No
X75XXXD Intentional self-harm by explosive material, subsequent encounter 58 58 59 Yes Yes Yes No
X75XXXS Intentional self-harm by explosive material, sequela 58 58 59 Yes Yes Yes No
X76XXXA Intentional self-harm by smoke, fire and flames, initial encounter 58 58 59 Yes Yes Yes No
X76XXXD Intentional self-harm by smoke, fire and flames, subsequent encounter 58 58 59 Yes Yes Yes No
X76XXXS Intentional self-harm by smoke, fire and flames, sequela 58 58 59 Yes Yes Yes No
X770XXA Intentional self-harm by steam or hot vapors, initial encounter 58 58 59 Yes Yes Yes No
X770XXD Intentional self-harm by steam or hot vapors, subsequent encounter 58 58 59 Yes Yes Yes No
X770XXS Intentional self-harm by steam or hot vapors, sequela 58 58 59 Yes Yes Yes No
X771XXA Intentional self-harm by hot tap water, initial encounter 58 58 59 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 243 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

X771XXD Intentional self-harm by hot tap water, subsequent encounter 58 58 59 Yes Yes Yes No
X771XXS Intentional self-harm by hot tap water, sequela 58 58 59 Yes Yes Yes No
X772XXA Intentional self-harm by other hot fluids, initial encounter 58 58 59 Yes Yes Yes No
X772XXD Intentional self-harm by other hot fluids, subsequent encounter 58 58 59 Yes Yes Yes No
X772XXS Intentional self-harm by other hot fluids, sequela 58 58 59 Yes Yes Yes No
X773XXA Intentional self-harm by hot household appliances, initial encounter 58 58 59 Yes Yes Yes No
X773XXD Intentional self-harm by hot household appliances, subsequent encounter 58 58 59 Yes Yes Yes No
X773XXS Intentional self-harm by hot household appliances, sequela 58 58 59 Yes Yes Yes No
X778XXA Intentional self-harm by other hot objects, initial encounter 58 58 59 Yes Yes Yes No
X778XXD Intentional self-harm by other hot objects, subsequent encounter 58 58 59 Yes Yes Yes No
X778XXS Intentional self-harm by other hot objects, sequela 58 58 59 Yes Yes Yes No
X779XXA Intentional self-harm by unspecified hot objects, initial encounter 58 58 59 Yes Yes Yes No
X779XXD Intentional self-harm by unspecified hot objects, subsequent encounter 58 58 59 Yes Yes Yes No
X779XXS Intentional self-harm by unspecified hot objects, sequela 58 58 59 Yes Yes Yes No
X780XXA Intentional self-harm by sharp glass, initial encounter 58 58 59 Yes Yes Yes No
X780XXD Intentional self-harm by sharp glass, subsequent encounter 58 58 59 Yes Yes Yes No
X780XXS Intentional self-harm by sharp glass, sequela 58 58 59 Yes Yes Yes No
X781XXA Intentional self-harm by knife, initial encounter 58 58 59 Yes Yes Yes No
X781XXD Intentional self-harm by knife, subsequent encounter 58 58 59 Yes Yes Yes No
X781XXS Intentional self-harm by knife, sequela 58 58 59 Yes Yes Yes No
X782XXA Intentional self-harm by sword or dagger, initial encounter 58 58 59 Yes Yes Yes No
X782XXD Intentional self-harm by sword or dagger, subsequent encounter 58 58 59 Yes Yes Yes No
X782XXS Intentional self-harm by sword or dagger, sequela 58 58 59 Yes Yes Yes No
X788XXA Intentional self-harm by other sharp object, initial encounter 58 58 59 Yes Yes Yes No
X788XXD Intentional self-harm by other sharp object, subsequent encounter 58 58 59 Yes Yes Yes No
X788XXS Intentional self-harm by other sharp object, sequela 58 58 59 Yes Yes Yes No
X789XXA Intentional self-harm by unspecified sharp object, initial encounter 58 58 59 Yes Yes Yes No
X789XXD Intentional self-harm by unspecified sharp object, subsequent encounter 58 58 59 Yes Yes Yes No
X789XXS Intentional self-harm by unspecified sharp object, sequela 58 58 59 Yes Yes Yes No
X79XXXA Intentional self-harm by blunt object, initial encounter 58 58 59 Yes Yes Yes No
X79XXXD Intentional self-harm by blunt object, subsequent encounter 58 58 59 Yes Yes Yes No
X79XXXS Intentional self-harm by blunt object, sequela 58 58 59 Yes Yes Yes No
X80XXXA Intentional self-harm by jumping from a high place, initial encounter 58 58 59 Yes Yes Yes No
X80XXXD Intentional self-harm by jumping from a high place, subsequent encounter 58 58 59 Yes Yes Yes No
X80XXXS Intentional self-harm by jumping from a high place, sequela 58 58 59 Yes Yes Yes No
X810XXA Intentional self-harm by jumping or lying in front of motor vehicle, initial encounter 58 58 59 Yes Yes Yes No
X810XXD Intentional self-harm by jumping or lying in front of motor vehicle, subsequent encounter 58 58 59 Yes Yes Yes No
X810XXS Intentional self-harm by jumping or lying in front of motor vehicle, sequela 58 58 59 Yes Yes Yes No
X811XXA Intentional self-harm by jumping or lying in front of (subway) train, initial encounter 58 58 59 Yes Yes Yes No
X811XXD Intentional self-harm by jumping or lying in front of (subway) train, subsequent encounter 58 58 59 Yes Yes Yes No
X811XXS Intentional self-harm by jumping or lying in front of (subway) train, sequela 58 58 59 Yes Yes Yes No
X818XXA Intentional self-harm by jumping or lying in front of other moving object, initial encounter 58 58 59 Yes Yes Yes No
X818XXD Intentional self-harm by jumping or lying in front of other moving object, subsequent encounter 58 58 59 Yes Yes Yes No
X818XXS Intentional self-harm by jumping or lying in front of other moving object, sequela 58 58 59 Yes Yes Yes No
X820XXA Intentional collision of motor vehicle with other motor vehicle, initial encounter 58 58 59 Yes Yes Yes No
X820XXD Intentional collision of motor vehicle with other motor vehicle, subsequent encounter 58 58 59 Yes Yes Yes No
X820XXS Intentional collision of motor vehicle with other motor vehicle, sequela 58 58 59 Yes Yes Yes No
X821XXA Intentional collision of motor vehicle with train, initial encounter 58 58 59 Yes Yes Yes No
X821XXD Intentional collision of motor vehicle with train, subsequent encounter 58 58 59 Yes Yes Yes No
X821XXS Intentional collision of motor vehicle with train, sequela 58 58 59 Yes Yes Yes No
X822XXA Intentional collision of motor vehicle with tree, initial encounter 58 58 59 Yes Yes Yes No

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 244 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

X822XXD Intentional collision of motor vehicle with tree, subsequent encounter 58 58 59 Yes Yes Yes No
X822XXS Intentional collision of motor vehicle with tree, sequela 58 58 59 Yes Yes Yes No
X828XXA Other intentional self-harm by crashing of motor vehicle, initial encounter 58 58 59 Yes Yes Yes No
X828XXD Other intentional self-harm by crashing of motor vehicle, subsequent encounter 58 58 59 Yes Yes Yes No
X828XXS Other intentional self-harm by crashing of motor vehicle, sequela 58 58 59 Yes Yes Yes No
X830XXA Intentional self-harm by crashing of aircraft, initial encounter 58 58 59 Yes Yes Yes No
X830XXD Intentional self-harm by crashing of aircraft, subsequent encounter 58 58 59 Yes Yes Yes No
X830XXS Intentional self-harm by crashing of aircraft, sequela 58 58 59 Yes Yes Yes No
X831XXA Intentional self-harm by electrocution, initial encounter 58 58 59 Yes Yes Yes No
X831XXD Intentional self-harm by electrocution, subsequent encounter 58 58 59 Yes Yes Yes No
X831XXS Intentional self-harm by electrocution, sequela 58 58 59 Yes Yes Yes No
X832XXA Intentional self-harm by exposure to extremes of cold, initial encounter 58 58 59 Yes Yes Yes No
X832XXD Intentional self-harm by exposure to extremes of cold, subsequent encounter 58 58 59 Yes Yes Yes No
X832XXS Intentional self-harm by exposure to extremes of cold, sequela 58 58 59 Yes Yes Yes No
X838XXA Intentional self-harm by other specified means, initial encounter 58 58 59 Yes Yes Yes No
X838XXD Intentional self-harm by other specified means, subsequent encounter 58 58 59 Yes Yes Yes No
X838XXS Intentional self-harm by other specified means, sequela 58 58 59 Yes Yes Yes No
Y622 Failure of sterile precautions during kidney dialysis and other perfusion 134 134 134 261 Yes Yes Yes Yes
Z21 Asymptomatic human immunodeficiency virus [HIV] infection status 1 1 1 1 Yes Yes Yes Yes
Z430 Encounter for attention to tracheostomy 82 82 82 Yes Yes Yes No
Z431 Encounter for attention to gastrostomy 188 188 188 Yes Yes Yes No
Z432 Encounter for attention to ileostomy 188 188 188 Yes Yes Yes No
Z433 Encounter for attention to colostomy 188 188 188 Yes Yes Yes No
Z434 Encounter for attention to other artificial openings of digestive tract 188 188 188 Yes Yes Yes No
Z435 Encounter for attention to cystostomy 188 188 188 Yes Yes Yes No
Z436 Encounter for attention to other artificial openings of urinary tract 188 188 188 Yes Yes Yes No
Z438 Encounter for attention to other artificial openings 188 188 188 Yes Yes Yes No
Z439 Encounter for attention to unspecified artificial opening 188 188 188 Yes Yes Yes No
Z44101 Encounter for fitting and adjustment of unspecified right artificial leg 189 189 189 Yes Yes Yes No
Z44102 Encounter for fitting and adjustment of unspecified left artificial leg 189 189 189 Yes Yes Yes No
Z44109 Encounter for fitting and adjustment of unspecified artificial leg, unspecified leg 189 189 189 Yes Yes Yes No
Z44111 Encounter for fitting and adjustment of complete right artificial leg 189 189 189 Yes Yes Yes No
Z44112 Encounter for fitting and adjustment of complete left artificial leg 189 189 189 Yes Yes Yes No
Z44119 Encounter for fitting and adjustment of complete artificial leg, unspecified leg 189 189 189 Yes Yes Yes No
Z44121 Encounter for fitting and adjustment of partial artificial right leg 189 189 189 Yes Yes Yes No
Z44122 Encounter for fitting and adjustment of partial artificial left leg 189 189 189 Yes Yes Yes No
Z44129 Encounter for fitting and adjustment of partial artificial leg, unspecified leg 189 189 189 Yes Yes Yes No
Z4821 Encounter for aftercare following heart transplant 186 186 186 396 Yes Yes Yes Yes
Z4822 Encounter for aftercare following kidney transplant 260 No No No Yes
Z4823 Encounter for aftercare following liver transplant 186 186 186 396 Yes Yes Yes Yes
Z4824 Encounter for aftercare following lung transplant 186 186 186 395 Yes Yes Yes Yes
Z48280 Encounter for aftercare following heart-lung transplant 186 186 186 395 Yes Yes Yes Yes
Z48280 Encounter for aftercare following heart-lung transplant 396 -- -- -- Yes
Z48290 Encounter for aftercare following bone marrow transplant 186 186 186 396 Yes Yes Yes Yes
Z4901 Encounter for fitting and adjustment of extracorporeal dialysis catheter 134 134 134 261 Yes Yes Yes Yes
Z4902 Encounter for fitting and adjustment of peritoneal dialysis catheter 134 134 134 261 Yes Yes Yes Yes
Z4931 Encounter for adequacy testing for hemodialysis 134 134 134 261 Yes Yes Yes Yes
Z4932 Encounter for adequacy testing for peritoneal dialysis 134 134 134 261 Yes Yes Yes Yes
Z6841 Body mass index [BMI]40.0-44.9, adult 22 22 22 43 Yes Yes Yes Yes
Z6842 Body mass index [BMI] 45.0-49.9, adult 22 22 22 43 Yes Yes Yes Yes
Z6843 Body mass index [BMI] 50.0-59.9, adult 22 22 22 43 Yes Yes Yes Yes

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 245 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

Z6844 Body mass index [BMI] 60.0-69.9, adult 22 22 22 43 Yes Yes Yes Yes
Z6845 Body mass index [BMI] 70 or greater, adult 22 22 22 43 Yes Yes Yes Yes
Z794 Long term (current) use of insulin 19 19 19 31 Yes Yes Yes Yes
Z89411 Acquired absence of right great toe 189 189 189 Yes Yes Yes No
Z89412 Acquired absence of left great toe 189 189 189 Yes Yes Yes No
Z89419 Acquired absence of unspecified great toe 189 189 189 Yes Yes Yes No
Z89421 Acquired absence of other right toe(s) 189 189 189 Yes Yes Yes No
Z89422 Acquired absence of other left toe(s) 189 189 189 Yes Yes Yes No
Z89429 Acquired absence of other toe(s), unspecified side 189 189 189 Yes Yes Yes No
Z89431 Acquired absence of right foot 189 189 189 Yes Yes Yes No
Z89432 Acquired absence of left foot 189 189 189 Yes Yes Yes No
Z89439 Acquired absence of unspecified foot 189 189 189 Yes Yes Yes No
Z89441 Acquired absence of right ankle 189 189 189 Yes Yes Yes No
Z89442 Acquired absence of left ankle 189 189 189 Yes Yes Yes No
Z89449 Acquired absence of unspecified ankle 189 189 189 Yes Yes Yes No
Z89511 Acquired absence of right leg below knee 189 189 189 Yes Yes Yes No
Z89512 Acquired absence of left leg below knee 189 189 189 Yes Yes Yes No
Z89519 Acquired absence of unspecified leg below knee 189 189 189 Yes Yes Yes No
Z89611 Acquired absence of right leg above knee 189 189 189 Yes Yes Yes No
Z89612 Acquired absence of left leg above knee 189 189 189 Yes Yes Yes No
Z89619 Acquired absence of unspecified leg above knee 189 189 189 Yes Yes Yes No
Z9115 Patient's noncompliance with renal dialysis 134 134 134 261 Yes Yes Yes Yes
Z930 Tracheostomy status 82 82 82 Yes Yes Yes No
Z931 Gastrostomy status 188 188 188 Yes Yes Yes No
Z932 Ileostomy status 188 188 188 Yes Yes Yes No
Z933 Colostomy status 188 188 188 Yes Yes Yes No
Z934 Other artificial openings of gastrointestinal tract status 188 188 188 Yes Yes Yes No
Z9350 Unspecified cystostomy status 188 188 188 Yes Yes Yes No
Z9351 Cutaneous-vesicostomy status 188 188 188 Yes Yes Yes No
Z9352 Appendico-vesicostomy status 188 188 188 Yes Yes Yes No
Z9359 Other cystostomy status 188 188 188 Yes Yes Yes No
Z936 Other artificial openings of urinary tract status 188 188 188 Yes Yes Yes No
Z938 Other artificial opening status 188 188 188 Yes Yes Yes No
Z939 Artificial opening status, unspecified 188 188 188 Yes Yes Yes No
Z940 Kidney transplant status 260 No No No Yes
Z941 Heart transplant status 186 186 186 396 Yes Yes Yes Yes
Z942 Lung transplant status 186 186 186 395 Yes Yes Yes Yes
Z943 Heart and lungs transplant status 186 186 186 395 Yes Yes Yes Yes
Z943 Heart and lungs transplant status 396 -- -- -- Yes
Z944 Liver transplant status 186 186 186 396 Yes Yes Yes Yes
Z9481 Bone marrow transplant status 186 186 186 396 Yes Yes Yes Yes
Z9482 Intestine transplant status 186 186 186 396 Yes Yes Yes Yes
Z9483 Pancreas transplant status 186 186 186 397 Yes Yes Yes Yes
Z9484 Stem cells transplant status 186 186 186 396 Yes Yes Yes Yes
Z95811 Presence of heart assist device 186 186 186 Yes Yes Yes No
Z95812 Presence of fully implantable artificial heart 186 186 186 Yes Yes Yes No
Z9911 Dependence on respirator [ventilator] status 82 82 82 Yes Yes Yes No
Z9912 Encounter for respirator [ventilator] dependence during power failure 82 82 82 Yes Yes Yes No
Z992 Dependence on renal dialysis 134 134 134 261 Yes Yes Yes Yes

Note:

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 246 of 247


Diagnosis Description CMS-HCC CMS-HCC CMS-HCC RxHCC CMS-HCC CMS-HCC CMS-HCC RxHCC
Code Model Model Model Model ESRD Model Model Category Model Category Model for
Category Category Category Category for 2021 V22 for 2021 V24 for 2021 2021
V21 V22 V24 V05 Payment Year Payment Year Payment Year Payment
Year

If an ICD-10 code includes clinical concepts comparable to two or more ICD-9 codes, it may map to more than one payment HCC or RxHCC. If that occurs, the ICD-10 code will repeat in separate rows for each of the multiple HCCs or
RxHCCs, with dashes in the repeating rows for the models in which the ICD-10 code maps only to a single HCC or RxHCC.

Output: icd10_udxgv0121_v21v22v24v05_p1.xlsx
Source: RTI International

FY20-FY21 ICD10 Payment Codes 540178593.xlsx 247 of 247

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