C40.01
BillableMalignant neoplasm of scapula and long bones of right upper limb
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is C40.01 an HCC code?
Yes. C40.01 maps to Lymphoma and Other Cancers under the CMS-HCC V28 risk adjustment model (and Lymphoma and Other Cancers 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 C40.01
For C40.01to 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 C40.01 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
C40.01 is the ICD-10-CM diagnosis code for malignant neoplasm of scapula and long bones of right upper limb. Cancer that starts in the shoulder blade or long bones of the right arm, including the upper arm and forearm bones. C40.01 sits in the ICD-10-CM chapter for neoplasms (c00-d49), within the section covering malignant neoplasms of bone and articular cartilage (c40-c41).
Under the CMS-HCC V28 risk adjustment model, C40.01 maps to Lymphoma and Other Cancers (HCC 21) with a community, non-dual, aged base RAF weight of 0.671. Under the older V24 model, C40.01 mapped to the same category but with a base RAF weight of 0.675 — 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.
Verify laterality is documented as right; if documentation is unclear, query the provider before coding. Because C40.01 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 C40.01 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Verify laterality is documented as right; if documentation is unclear, query the provider before coding
- •Long bones of upper limb include humerus, radius, and ulna; ensure the specific bone location is documented for accuracy
Clinical Significance
Right-sided bone cancer of the scapula and upper limb long bones specifies laterality, which is critical for surgical planning — limb-salvage procedures, reconstruction, and potential amputation decisions all depend on which side is affected. Right upper extremity tumors have particular functional significance as most patients are right-hand dominant.
Documentation Requirements
- ✓Pathology confirming primary bone malignancy with histological type and grade
- ✓Imaging confirming right-sided location with specific bone identification
- ✓Explicit right laterality documentation
- ✓TNM staging and assessment for limb-salvage candidacy
- ✓Functional assessment of the affected extremity
Commonly Confused Codes
- •C40.02 — Left upper limb long bones: Verify right laterality from documentation
- •C40.00 — Unspecified laterality: Use C40.01 when right side is documented
- •C79.51 — Secondary malignant neoplasm of bone: Confirm primary origin, not metastatic
- •C40.10-C40.12 — Short bones of upper limb (hand): Long bones are proximal; short bones are in the hand and wrist