E72.538 ICD-10-CM Code: Other specified primary hyperoxaluria
E72.538 maps to CMS-HCC V28 50 (RAF 0.648). Documentation must support MEAT. MEAT criteria · RAF calculator · free HCC coding tools
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FY 2026 Apr update / Endocrine, nutritional and metabolic diseases (E00-E89) / Metabolic disorders (E70-E88)
E72.538
Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidanceOther specified primary hyperoxaluria
Other specified forms of primary hyperoxaluria, a genetic disorder causing excessive oxalate production, excluding the more common type 1 variant.
CMS-HCC V28
MappedHCC 50
RAF 0.648
CMS-HCC V24
N/A—
Not mapped
ACA/HHS
MappedHCC 28
Varies by metal level
ESRD/PACE
MappedHCC 23
RAF 0.036
RXHCC
MappedHCC 43
RAF 0.063
Code Book Path
Inclusion Terms
Official- Primary hyperoxaluria, type 2
- Primary hyperoxaluria, type 3
Excludes 2
OfficialICD-10-CM does not list Excludes 2 notes for E72.538 in this effective period.
Related Child Codes
Includes
OfficialICD-10-CM does not list Includes notes for E72.538 in this effective period.
Excludes 1
Official- secondary hyperoxaluria (E72.54-)
Code First
OfficialICD-10-CM does not list Code First sequencing instructions for E72.538 in this effective period.
Use Additional
OfficialICD-10-CM does not list Use Additional Code instructions for E72.538 in this effective period.
Code Also
OfficialICD-10-CM does not list Code Also instructions for E72.538 in this effective period.
Buddy Documentation Tip
Current with CMS: FY2026 ICD-10-CM Apr 1 update (effective Apr 1 – Sep 30, 2026) · CMS-HCC V28, 100% phased in for payment year 2026. FY2027 code set already staged for October 1, 2026. How HCC Buddy stays current →
Is E72.538 an HCC code?
Yes. E72.538 (Other specified primary hyperoxaluria) maps to Amyloidosis, Porphyria, and Other Specified Metabolic Disorders under the CMS-HCC V28 risk adjustment model, with a community non-dual aged RAF of 0.648. It is billable for payment year 2026.
Coder answer: E72.538 is billable and maps to V28 HCC 50, Amyloidosis, Porphyria, and Other Specified Metabolic Disorders. Open it in the Code Book for the tabular path, RAF, and MEAT checklist.
- Code
- E72.538
- Description
- Other specified primary hyperoxaluria
- HCC (V28)
- HCC 50 — Amyloidosis, Porphyria, and Other Specified Metabolic Disorders
- RAF
- 0.648
- Billable
- Yes
- Payment year
- 2026
HCC Category Mapping
Each model's RAF is its CMS base weight for that model's standard population, so weights are not directly comparable across models: CMS-HCC V28 and V24 use Community, Non-Dual, Aged; ESRD uses the dialysis continuing-enrollee model; RxHCC is the Part D continuing-enrollee, non-low-income, aged weight (a larger scale than CMS-HCC). ACA/HHS has no single weight — it varies by metal level. 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.
Work E72.538 in the Code Book — tabular path, V28 RAF, and MEAT checklist →
MEAT Criteria for E72.538
For E72.538 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 E72.538 during that encounter, not just copy-forwarded from a problem list.
Coder workflow notes
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What This Code Means
E72.538 is the ICD-10-CM diagnosis code for other specified primary hyperoxaluria. Other specified forms of primary hyperoxaluria, a genetic disorder causing excessive oxalate production, excluding the more common type 1 variant. E72.538 sits in the ICD-10-CM chapter for endocrine, nutritional and metabolic diseases (e00-e89), within the section covering metabolic disorders (e70-e88).
Under the CMS-HCC V28 risk adjustment model, E72.538 maps to Amyloidosis, Porphyria, and Other Specified Metabolic Disorders (HCC 50) with a community, non-dual, aged base RAF weight of 0.648. E72.538 was not retained as a payment HCC under the older V24 model, so V28 introduced or recategorized it during the 2024–2026 phase-in. 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.
Use this code only when the specific type of primary hyperoxaluria is documented but does not fit type 1. Because E72.538 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 E72.538 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Use this code only when the specific type of primary hyperoxaluria is documented but does not fit type 1
- •Document the specific type identified (such as type 2 or type 3) in the medical record