B37.81
BillableCandidal esophagitis
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is B37.81 an HCC code?
Yes. B37.81 maps to Opportunistic Infections under the CMS-HCC V28 risk adjustment model (and Opportunistic Infections under V24).
HCC Category Mapping
RAF weights shown are the community, non-dual, aged base weights from the CMS risk adjustment model file. Actual per-patient RAF contribution depends on member segment, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains in use during the transition and for historical data.
MEAT Criteria for B37.81
For B37.81 to count as a valid HCC diagnosis in a given encounter, the provider's documentation must show MEAT: Monitor, Evaluate, Assess, or Treat. A diagnosis from a prior year does not carry forward automatically — it has to be re-documented and supported each calendar year.
- MMonitor: signs, symptoms, disease progression, or lab trending documented in the note
- EEvaluate: test results, medication response, or physical findings reviewed by the provider
- AAssess: explicit mention in the assessment or plan with acknowledgment of status
- TTreat: medication, referral, procedure, therapy, or counseling tied to the diagnosis
Only one of M/E/A/T is required to support the code, but the documentation must be specific enough to show that the provider actually addressed B37.81 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
B37.81 is the ICD-10-CM diagnosis code for candidal esophagitis. A yeast infection of the esophagus (food pipe) that causes difficulty swallowing, pain, and discomfort. B37.81 sits in the ICD-10-CM chapter for certain infectious and parasitic diseases (a00-b99), within the section covering mycoses (b35-b49).
Under the CMS-HCC V28 risk adjustment model, B37.81 maps to Opportunistic Infections (HCC 6) with a community, non-dual, aged base RAF weight of 0.439. Under the older V24 model, B37.81 mapped to the same category but with a base RAF weight of 0.440 — V28 recalibrated weights across the entire model. V28 is the CMS-HCC risk adjustment model that reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition.
Common in immunocompromised patients, especially those with HIV/AIDS; document immune status if available. Because B37.81 maps to a payment HCC, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's Medicare Advantage risk adjustment score. When documentation is ambiguous, coders should issue a provider query rather than assume the highest-specificity variant.
HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for B37.81 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Common in immunocompromised patients, especially those with HIV/AIDS; document immune status if available
- •Endoscopy findings typically confirm diagnosis; verify documentation mentions esophageal involvement specifically
Clinical Significance
Candidal esophagitis is a hallmark opportunistic infection strongly associated with immunocompromised states, particularly HIV/AIDS with CD4 counts below 200. Its presence signals significant immune dysfunction and carries a high RAF weight, making accurate capture essential for reflecting true patient acuity in risk adjustment models.
Documentation Requirements
- ✓Endoscopy findings confirming esophageal candidiasis (white plaques, mucosal erythema)
- ✓Culture or histopathologic confirmation of Candida species when available
- ✓Underlying immunocompromised condition documented (HIV status, CD4 count, transplant, chemotherapy)
- ✓Symptoms documented: dysphagia, odynophagia, retrosternal pain
- ✓Current and prior antifungal treatment regimen
Commonly Confused Codes
- •B37.0 (Candidal stomatitis) - oral thrush affecting the mouth only, not the esophagus; esophageal involvement requires B37.81
- •K20.9 (Esophagitis, unspecified) - non-infectious esophagitis; if Candida is the cause, use B37.81 instead
- •B37.89 (Other sites of candidiasis) - use only when candidiasis affects sites other than esophagus, mouth, or other specified locations