G40.219
BillableLocalization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is G40.219 an HCC code?
Yes. G40.219 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 G40.219
For G40.219 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 G40.219 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
G40.219 is the ICD-10-CM diagnosis code for localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without 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, but the patient is not currently in status epilepticus. G40.219 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, G40.219 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, G40.219 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.
The '9' in the fifth character indicates absence of status epilepticus, which is the key distinction from G40.211. Because G40.219 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 G40.219 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •The '9' in the fifth character indicates absence of status epilepticus, which is the key distinction from G40.211
- •Document the frequency and severity of breakthrough seizures despite medication compliance to support the intractable diagnosis
Clinical Significance
This code captures symptomatic focal epilepsy with complex partial seizures that is drug-resistant but without current status epilepticus. These patients have ongoing seizures with impaired consciousness despite adequate medication trials. They often require evaluation for epilepsy surgery, vagus nerve stimulation, or other advanced interventions to achieve seizure control.
Documentation Requirements
- ✓Documentation of symptomatic focal epilepsy with identified underlying cause
- ✓Complex partial seizure type (impaired consciousness) documented
- ✓Evidence of intractability: at least 2 failed adequate antiepileptic medication trials
- ✓Ongoing seizure frequency documentation despite treatment compliance
- ✓Underlying structural or metabolic cause identified and coded separately
- ✓Evaluation for advanced treatment options (surgery, neurostimulation) if applicable
Commonly Confused Codes
- •G40.209 — Same type, NOT intractable; medication responsive
- •G40.211 — Same type, intractable, WITH status epilepticus; acute emergency
- •G40.119 — Symptomatic focal with SIMPLE partial seizures, intractable; consciousness preserved
- •G40.319 — Generalized idiopathic epilepsy, intractable; generalized onset
- •G40.919 — Epilepsy unspecified, intractable; less specific