G40.211
BillableLocalization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is G40.211 an HCC code?
Yes. G40.211 maps to Seizure Disorders and Convulsions under the CMS-HCC V28 risk adjustment model (and Seizure Disorders and Convulsions 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 G40.211
For G40.211 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 G40.211 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
G40.211 is the ICD-10-CM diagnosis code for localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus. A type of epilepsy that starts in one area of the brain and causes complex partial seizures that are difficult to control with medication, and the patient is currently experiencing status epilepticus (prolonged or repeated seizures). G40.211 sits in the ICD-10-CM chapter for diseases of the nervous system (g00-g99), within the section covering episodic and paroxysmal disorders (g40-g47).
Under the CMS-HCC V28 risk adjustment model, G40.211 maps to Seizure Disorders and Convulsions (HCC 201) with a community, non-dual, aged base RAF weight of 0.262. Under the older V24 model, G40.211 mapped to the same category but with a base RAF weight of 0.244 — 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.
Status epilepticus (the '1' in the fifth character) indicates a medical emergency requiring immediate documentation and treatment. Because G40.211 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 G40.211 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Status epilepticus (the '1' in the fifth character) indicates a medical emergency requiring immediate documentation and treatment
- •Verify that the seizures are confirmed as intractable (drug-resistant) before coding, as this affects treatment planning and prognosis
Clinical Significance
This code represents a medical emergency — symptomatic focal epilepsy with complex partial seizures that is drug-resistant and the patient is in active status epilepticus. The combination of intractable seizures and status epilepticus with impaired consciousness represents one of the most critical scenarios in epilepsy management, often requiring ICU-level care.
Documentation Requirements
- ✓Documentation of symptomatic focal epilepsy with a known underlying cause
- ✓Complex partial seizure type documented (impaired consciousness)
- ✓Evidence of intractability with documented medication failure history
- ✓Active status epilepticus with onset time, duration, and emergency interventions
- ✓EEG monitoring documentation if nonconvulsive status is suspected
- ✓ICU admission documentation and treatment escalation plan
- ✓Underlying etiology coded separately
Commonly Confused Codes
- •G40.219 — Same type, intractable, WITHOUT status epilepticus; non-emergency intractable state
- •G40.201 — Same type, NOT intractable, WITH status epilepticus; breakthrough in normally controlled epilepsy
- •G40.111 — Symptomatic focal with SIMPLE partial seizures, intractable, with status epilepticus; consciousness preserved
- •G40.311 — Generalized idiopathic epilepsy, intractable, with status epilepticus; generalized onset
- •G40.011 — IDIOPATHIC focal, intractable, with status epilepticus; no identified cause