Risk Adjustment Eligible CPT Codes — 2026 Reference

The Quick Answer

Not every medical encounter counts for HCC risk adjustment. For CY2026, CMS accepts diagnoses only from encounters billed with specific CPT and HCPCS codes that represent face-to-face or approved telehealth visits between a patient and an eligible provider. Lab-only encounters, radiology-only encounters, DME claims, and most ancillary services are excluded. The eligible encounter types include office and outpatient E/M visits (99202-99215), hospital inpatient and observation visits, emergency department visits, Annual Wellness Visits (G0438, G0439), and certain telehealth-eligible codes — but only when the visit meets the face-to-face or interactive audio/video requirements. Understanding which CPT codes qualify is foundational: if the encounter type is not eligible, none of the diagnoses from that encounter will be accepted for risk adjustment, no matter how accurately they are coded.

Why Encounter Eligibility Matters More Than Most Coders Realize

Risk adjustment coding accuracy gets most of the attention in HCC training. Coders spend hours learning ICD-10 specificity, MEAT documentation, hierarchy rules, and V28 mappings. But none of that work matters if the diagnoses come from an encounter type that CMS does not accept for risk adjustment data submission.

This is the upstream gate. CMS filters risk adjustment data at the encounter level before it ever evaluates the diagnosis codes attached to that encounter. A perfectly documented, perfectly coded HCC diagnosis on a lab-only claim is worth zero RAF value because the encounter itself is not eligible.

The rules for encounter eligibility come from CMS's annual Risk Adjustment Eligible Encounter and Diagnosis Filtering guidance, updated each payment year. For PY2026, the filtering criteria determine which CPT and HCPCS codes on submitted claims will have their diagnoses accepted into the Risk Adjustment Processing System (RAPS) and the Encounter Data Processing System (EDPS).

RAPS vs EDPS: Two Submission Pathways, Same Eligibility Core

Before diving into the specific CPT codes, it is important to understand the two systems that accept risk adjustment data from Medicare Advantage plans.

RAPS (Risk Adjustment Processing System) is the legacy submission pathway. Plans submit diagnosis clusters — combinations of a beneficiary ID, provider information, dates of service, and ICD-10-CM codes — directly to RAPS. RAPS uses its own filtering logic to accept or reject submitted diagnoses based on encounter type.

EDPS (Encounter Data Processing System) is the newer, more comprehensive pathway. Plans submit full encounter data (essentially complete claim-level records) to EDPS, and CMS extracts the risk adjustment-eligible diagnoses from that data. EDPS applies its own filtering criteria, which are largely aligned with RAPS but operate on the full claim record rather than on abstracted diagnosis clusters.

For PY2026, CMS continues to use a blend of both RAPS and EDPS data in calculating risk scores. The eligible encounter types are fundamentally the same across both systems, though the technical submission mechanics differ. The key point for coders: if an encounter type is not on the eligible list, its diagnoses will be filtered out of both RAPS and EDPS.

The Core Principle: Face-to-Face With an Eligible Provider

The overarching rule for risk adjustment encounter eligibility is straightforward: the encounter must involve a face-to-face interaction (or approved telehealth equivalent) between the beneficiary and a qualified healthcare provider. This means the provider must personally evaluate the patient, not just order a test or review a result.

Eligible provider types include physicians (MD/DO), nurse practitioners, physician assistants, clinical nurse specialists, and other providers recognized by Medicare for E/M billing purposes. The provider must be the one documenting the diagnoses based on their direct assessment of the patient.

This face-to-face requirement is what excludes entire categories of healthcare services from risk adjustment eligibility, including:

Eligible CPT Code Categories for CY2026

The following CPT and HCPCS code categories are accepted for risk adjustment data submission in CY2026. This is not an exhaustive list of every individual code, but it covers the categories and ranges that coders encounter most frequently.

Office and Outpatient E/M Visits (99202-99215)

These are the workhorses of risk adjustment coding. The vast majority of HCC diagnoses captured in Medicare Advantage come from office-based E/M visits.

All of these codes are risk adjustment eligible. Note that 99211 (the nurse visit code that does not require the presence of a physician) is technically eligible, but diagnoses from 99211 encounters receive more scrutiny in RADV audits because the documentation often lacks the physician assessment detail expected for chronic condition recapture.

Hospital Inpatient E/M Visits

Inpatient encounters are eligible and often capture the highest-acuity diagnoses.

All inpatient E/M codes involve face-to-face provider assessment and are fully eligible for risk adjustment.

Hospital Observation Services

Emergency Department Visits

ED visits are risk adjustment eligible. They are a significant source of acute diagnoses (acute MI, stroke, respiratory failure, sepsis) that map to high-value HCCs. However, coders should note that ED diagnoses sometimes reflect "rule-out" or "suspected" conditions that do not meet the documentation threshold for HCC capture. Only confirmed diagnoses should be submitted for risk adjustment.

Consultations

Important caveat: CMS eliminated separate payment for consultation codes in 2010 for Medicare billing purposes, and most Medicare Advantage plans follow this policy. However, consultation CPT codes still appear on some claims and are technically in the eligible encounter filter. In practice, most consultations are billed using standard E/M visit codes (99202-99215 or 99221-99223) rather than consultation-specific codes.

Annual Wellness Visits

AWV encounters are critically important for risk adjustment because they are designed to capture and update a patient's complete problem list. A well-conducted AWV should reassess every active chronic condition, making it the ideal encounter for HCC recapture. Both G0438 and G0439 are fully risk adjustment eligible.

Also eligible:

Skilled Nursing Facility (SNF) Visits

SNF encounters are eligible and are an important source of risk adjustment data for the institutionalized population, which has its own CMS-HCC model segment.

Home Services

Home visits are face-to-face encounters and are fully eligible. With the growth of home-based primary care programs, these codes are becoming more common in risk adjustment data.

Domiciliary, Rest Home, or Custodial Care Services

These are eligible and apply to patients in assisted living facilities and similar settings.

Telehealth Visits

Telehealth eligibility for risk adjustment is one of the most commonly misunderstood areas. Here is what coders need to know for CY2026:

Eligible telehealth encounters are those billed with a telehealth-eligible CPT code and delivered via real-time, interactive audio/video communication. The encounter must be a synchronous visit where the provider can see and interact with the patient in real time.

The telehealth-eligible CPT codes that qualify for risk adjustment are the same E/M codes listed above (99202-99215, 99221-99223, etc.) when they are billed with the appropriate telehealth modifier (modifier -95 or place of service code 02) and meet CMS's telehealth requirements.

Common misconception: Not all telehealth visits are risk adjustment eligible. The following are NOT eligible:

The bottom line on telehealth: If it is a real-time video visit billed with a standard E/M code and the appropriate telehealth modifier, it is likely eligible. If it is audio-only, asynchronous, or a non-E/M technology service, it is likely not eligible. Always verify against the current CMS telehealth eligible services list.

Transitional Care Management (TCM)

TCM codes include a required face-to-face visit component and are risk adjustment eligible.

Chronic Care Management (CCM) and Related Services

Important: Standard CCM codes (99490, 99489) represent non-face-to-face care coordination services and are generally not risk adjustment eligible because they do not involve a face-to-face encounter. However, 99491 (the complex CCM code requiring a face-to-face visit) may be eligible. Coders should verify each code's eligibility status against CMS's current filtering criteria rather than assuming all CCM codes qualify.

Encounter Types That Are NOT Eligible

To reinforce the core eligibility principle, here is an explicit list of encounter types that do not qualify for risk adjustment data submission:

Practical Tips for Coders

1. Check the encounter type before you code. Before spending time on ICD-10 specificity, MEAT documentation, and HCC mapping, verify that the encounter itself is eligible. If the claim is a lab-only or imaging-only encounter, no diagnosis from that claim will be accepted for risk adjustment.

2. Link diagnoses to eligible encounters. When a patient has a lab visit and an office visit on the same day, make sure the HCC-relevant diagnoses are documented and coded on the office visit claim, not just the lab order.

3. Know the telehealth rules. Telehealth encounters are eligible only when they meet the real-time, interactive audio/video standard and are billed with appropriate modifiers. Do not assume every virtual encounter counts.

4. Use Annual Wellness Visits strategically. AWVs are one of the best opportunities for comprehensive HCC recapture. Every active chronic condition should be reassessed and documented during the AWV.

5. Watch for split encounters. When a patient has multiple encounter types on the same date of service (for example, an E/M visit and a separate procedure), ensure the HCC diagnoses are attached to the E/M visit claim, which is the eligible encounter.

6. Stay current with CMS updates. The eligible encounter list is updated annually. Telehealth eligibility in particular has been in flux since 2020 and continues to evolve. Check the CMS risk-adjustment hub for the current payment year's Eligible Encounter guidance, and cross-reference any CPT or ICD-10 question against the CMS ICD-10-CM code set.

How HCC Buddy Helps

Knowing which encounters are eligible is the first step. The next step is ensuring that every eligible encounter captures every documented, supportable HCC diagnosis. HCC Buddy's ICD-10 Encoder lets you look up any diagnosis code and instantly see its HCC mapping, so you can prioritize coding on eligible encounters that carry HCC value. The RAF Calculator shows you the downstream financial impact of captured diagnoses, and the Payer Guidelines tool helps you verify payer-specific requirements for encounter submission.

Risk adjustment coding is a chain: eligible encounter, documented diagnosis, accurate ICD-10 code, valid HCC mapping. If any link breaks, the RAF value is lost. Start with the encounter eligibility check, and work forward from there.