Condition guide
Heart Failure HCC Coding Guide
Heart Failure (e.g. I50.9) maps to HCC 226 (Heart Failure, Except End Stage and Acute) under CMS-HCC V28. Its source-labeled community non-dual aged reference coefficient is 0.360. This is not a member total; full contribution depends on hierarchy, cleanup, interactions, member context, and model year. 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.
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
How coders write it
Chart notes, problem lists, and queries rarely spell out Heart Failure. The shorthand you will actually see:
Whatever the note calls it, the payment question is the same: how the ICD-10-CM code resolves to a payment HCC.
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 |
Displayed numbers are source-labeled community non-dual aged reference coefficients from CMS-HCC V28, not member totals.
Verify Heart Failure against the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coder workflow notes
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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) as part of the treatment review.
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).
MEAT documentation examples for Heart Failure
These examples organize documentation review using the MEAT review mnemonic for Heart Failure. Follow the applicable coding, encounter, program and payer requirements; these examples do not establish reportability on their own.
MMonitor
“Daily weights reviewed: up 3 pounds over two weeks.”
“BNP 890 today, up from 420 at the last visit.”
“Echo reviewed: EF 32 percent, unchanged from prior study.”
EEvaluate
“Exam: 2+ pitting edema to mid-shin, bibasilar crackles, JVD present.”
“NYHA class III today, up from class II at the last visit.”
“Home blood pressure and heart rate logs reviewed on carvedilol.”
AAssess
“Chronic systolic heart failure (HFrEF, EF 32 percent), decompensating.”
“Acute on chronic diastolic heart failure, volume overloaded.”
“HFpEF, stable on current regimen.”
TTreat
“Furosemide increased to 80 mg daily; low-sodium counseling provided.”
“Started sacubitril-valsartan and stopped lisinopril; titrating.”
“Added empagliflozin per guideline-directed therapy.”
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 collapsed into one congestive heart failure category, HCC 85, at a community RAF of 0.331. 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 the three carries the same RAF of 0.36, so the acuity you document drives which HCC is assigned rather than the dollar weight. In the hierarchy, HCC 224 supersedes 225 and 226, so a year that contains both a decompensation and routine chronic visits resolves to the acute-on-chronic category. Hypertensive heart disease with heart failure (I11.0) rides the same HCC 226 as the chronic I50 codes, so the etiology combination still earns heart failure credit.
| Aspect | V24 (through PY2025) | V28 (PY2026) |
|---|---|---|
| Category structure | One category: HCC 85, Congestive Heart Failure, RAF 0.331 | Three acuity categories: HCC 224, HCC 225, HCC 226, RAF 0.360 each |
| Chronic or unspecified HF (I50.22, I50.32, I50.9) | HCC 85, RAF 0.331 | HCC 226, Heart Failure Except End Stage and Acute, RAF 0.360 |
| Acute on chronic HF (I50.23, I50.33, I50.43) | HCC 85, no extra recognition for acuity | HCC 224, its own category, RAF 0.360 |
| Acute HF (I50.21, I50.31) | HCC 85, RAF 0.331 | HCC 225, RAF 0.360 |
| Hypertensive heart disease with HF (I11.0) | HCC 85, RAF 0.331 | HCC 226, RAF 0.360 |
These values are community, non-dual, aged code-level coefficient references for each model's payment year, not full member scores. For CMS-HCC V28 PY2026 member scoring with complete context, open the RAF Calculator. No score is shown unless every required source and calculation check passes.
Heart Failure coding FAQs
What HCC is CHF in V28?
Chronic and unspecified heart failure codes (I50.22, I50.32, I50.9) map to HCC 226 with a community, non-dual, aged RAF weight of 0.360. Acute heart failure maps to HCC 225 and acute on chronic to HCC 224, each also 0.360. Under V24 all of these shared a single category, HCC 85, at 0.331.
Does documenting acuity change the heart failure RAF weight?
Not the dollar weight; all three V28 heart failure categories pay 0.360 at community, non-dual, aged rates. It changes the category and the hierarchy: HCC 224 (acute on chronic) supersedes HCC 225 and HCC 226 when more than one appears in the year. Acuity documentation also keeps the record audit-defensible, which is reason enough to capture it.
Is hypertensive heart disease with heart failure an HCC code?
Yes. I11.0 maps to V28 HCC 226, the same category as the chronic I50 codes, so the hypertensive-etiology combination earns full heart failure credit. Code the specific I50 heart failure type alongside it when documented.
Related Conditions
Coronary Artery Disease
HCC 229, RAF 0.240
Atrial Fibrillation
HCC 238, RAF 0.299
Chronic Kidney Disease
HCC 326, HCC 327, HCC 329, HCC 328, RAF 0.815–0.514–0.127–0.127
Chronic Obstructive Pulmonary Disease (COPD)
HCC 213, HCC 280, RAF 0.370–0.319
Diabetes Mellitus (Type 2)
HCC 383, HCC 298, HCC 38, HCC 37, RAF 0.646–0.336–0.166–0.166
Related references
CMS-HCC V28 model
How V28 categories, source-labeled coefficient references, and hierarchy work for PY2026.
ICD-10 to HCC mapping
How an ICD-10-CM code resolves to a payment HCC under V28.
MEAT criteria
The documentation standard every coded condition must satisfy.
CMS-HCC V28 PY2026, complete member context required. No score is shown unless every required check passes.
Sources
Displayed numbers are source-labeled community non-dual aged reference coefficients from CMS-HCC V28, not member totals.
Verified current to CMS-HCC V28, payment year 2026 — last reviewed September 5, 2026.
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