Heart Failure HCC Coding Guide
Heart Failure (e.g. I50.9) maps to HCC 226 (Heart Failure, Except End Stage and Acute) under the CMS-HCC V28 risk adjustment model, with a community, non-dual, aged RAF weight of 0.360; V28 reached 100% phase-in for payment year 2026. It can also map to HCC 224 (Acute on Chronic Heart Failure) and HCC 225 (Acute Heart Failure (Excludes Acute on Chronic)) when the documentation supports those manifestations.
Complete HCC coding guide for Heart Failure (I50.x) including ICD-10 to HCC mapping, V28 RAF weights, ejection fraction documentation, and systolic vs. diastolic coding.
Medically reviewed by Jess P., CPC · Reviewed: May 9, 2026 · Updated for CMS-HCC V28 and FY2026 ICD-10-CM
Quick Facts
HCC Categories
HCC 226, Heart Failure, Except End Stage and Acute
HCC 224, Acute on Chronic Heart Failure
HCC 225, Acute Heart Failure (Excludes Acute on Chronic)
RAF Weight Range
0.360
Community, non-dual, aged (V28)
Model
CMS-HCC V28 (PY2026, 100% phase-in)
10 ICD-10 codes map to payment HCCs
What HCC category does Heart Failure map to under V28?
Heart failure affects roughly 6.7 million Americans and is a high-value condition in risk adjustment. Under CMS-HCC V28, heart failure does not roll up into one category. Instead, the I50 codes split across three acuity-based HCCs: HCC 226 (Heart Failure, Except End Stage and Acute) for chronic and unspecified types, HCC 224 (Acute on Chronic Heart Failure) for decompensation on a chronic baseline, and HCC 225 (Acute Heart Failure, Excludes Acute on Chronic) for new acute events. Each carries a community non-dual aged RAF of 0.36. Accurate coding means documenting the type (systolic, diastolic, or combined), the acuity, and the ejection fraction, then choosing the I50 code that captures both type and acuity.
ICD-10 to HCC Mapping
| ICD-10 Code | Description | Billable | HCC Mapping |
|---|---|---|---|
| I50.20 | Unspecified systolic (congestive) heart failure | Yes | HCC 226 |
| I50.22 | Chronic systolic (congestive) heart failure | Yes | HCC 226 |
| I50.23 | Acute on chronic systolic (congestive) heart failure | Yes | HCC 224 |
| I50.30 | Unspecified diastolic (congestive) heart failure | Yes | HCC 226 |
| I50.32 | Chronic diastolic (congestive) heart failure | Yes | HCC 226 |
| I50.42 | Chronic combined systolic and diastolic (congestive) heart failure | Yes | HCC 226 |
| I50.9 | Heart failure, unspecified | Yes | HCC 226 |
| I50.21 | Acute systolic (congestive) heart failure | Yes | HCC 225 |
| I50.33 | Acute on chronic diastolic (congestive) heart failure | Yes | HCC 224 |
| I11.0 | Hypertensive heart disease with heart failure | Yes | HCC 226 |
RAF weights are community, non-dual, aged base coefficients from the CMS-HCC V28 model (PY2026). Verify against the latest CMS rate announcement for payment calculations.
HCC Buddy maps Heart Failure from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Documentation Tips
Document the type of heart failure: systolic (HFrEF), diastolic (HFpEF), or combined systolic and diastolic.
Always include the most recent left ventricular ejection fraction (LVEF) percentage in the encounter note.
Specify the acuity: acute, chronic, or acute-on-chronic, this determines the 4th and 5th character of the I50 code.
Document the current NYHA functional class (I-IV) to support severity and medical necessity.
Record current medications (ACE inhibitors, beta-blockers, diuretics, SGLT2 inhibitors) to satisfy MEAT treatment criteria.
When heart failure is decompensated, document the specific findings (dyspnea, edema, weight gain, BNP elevation).
Note co-existing conditions that contribute to or result from heart failure (CKD, atrial fibrillation, pulmonary hypertension).
Common Coding Mistakes
Coding I50.9 (heart failure, unspecified) when the provider has documented systolic or diastolic dysfunction, always code to the specific type.
Failing to capture acute-on-chronic heart failure (I50.23 or I50.33) during hospital encounters when a chronic patient presents with decompensation.
Not linking heart failure with its underlying etiology (hypertensive heart disease I11.0, cardiomyopathy I42.x) when documented.
Missing the diastolic heart failure code when the provider documents HFpEF or preserved ejection fraction.
V24 to V28 Changes
Under V24, heart failure largely collapsed into one congestive heart failure category. V28 replaced that with three separate acuity-based categories: HCC 226 for chronic or unspecified heart failure, HCC 224 for acute on chronic heart failure, and HCC 225 for acute heart failure (excluding acute on chronic). At current community non-dual aged factors each of these three carries the same RAF of 0.36, so the acuity you document drives which HCC is assigned rather than the dollar weight. Specificity still matters: capturing acute versus acute on chronic versus chronic keeps the record audit-defensible, and related diagnoses such as hypertensive heart disease with heart failure (I11.0) map to their own separate HCC, not to the I50 categories.
Related Conditions
Related references
Sources
RAF weights are community, non-dual, aged base coefficients from the CMS-HCC V28 model (PY2026). Verify against the latest CMS Rate Announcement for payment.
Verified current to CMS-HCC V28, payment year 2026 — last reviewed May 9, 2026.
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