G40.803
BillableOther epilepsy, intractable, with status epilepticus
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is G40.803 an HCC code?
Yes. G40.803 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 G40.803
For G40.803 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 G40.803 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
G40.803 is the ICD-10-CM diagnosis code for other epilepsy, intractable, with status epilepticus. A form of epilepsy that doesn't fit other specific categories and cannot be adequately controlled with medication, currently experiencing a prolonged seizure state. G40.803 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, G40.803 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, G40.803 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.
Intractable epilepsy indicates medication-resistant seizures; document failed medication trials. Because G40.803 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 G40.803 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Intractable epilepsy indicates medication-resistant seizures; document failed medication trials
- •Status epilepticus in intractable epilepsy represents a critical emergency requiring specialized intervention
Clinical Significance
Other epilepsy, intractable, with status epilepticus represents a critical combination of drug-resistant epilepsy in a life-threatening prolonged seizure state. These patients have failed adequate medication trials and are in acute seizure emergency, typically requiring ICU-level care, IV medications, and possibly intubation. This is among the highest-acuity epilepsy presentations.
Documentation Requirements
- ✓Documentation of intractable/drug-resistant epilepsy with failed medication trials
- ✓Active status epilepticus documented during the encounter
- ✓List of antiepileptic drugs attempted and failed
- ✓Emergency interventions and ICU care provided
- ✓Epilepsy type documentation explaining why specific syndromes do not apply
- ✓Assessment for surgical or device-based treatment candidacy