G40.B11
BillableJuvenile myoclonic 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.B11 an HCC code?
Yes. G40.B11 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.B11
For G40.B11 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.B11 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
G40.B11 is the ICD-10-CM diagnosis code for juvenile myoclonic epilepsy, intractable, with status epilepticus. Juvenile myoclonic epilepsy that does not respond adequately to medication treatment, with the patient currently experiencing status epilepticus, which is a serious condition of prolonged or repeated seizures. G40.B11 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.B11 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.B11 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.
Document that seizures are intractable (drug-resistant) and that status epilepticus is present during the encounter. Because G40.B11 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.B11 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Document that seizures are intractable (drug-resistant) and that status epilepticus is present during the encounter
- •Status epilepticus is a medical emergency; ensure appropriate emergency care documentation is included
Clinical Significance
Intractable juvenile myoclonic epilepsy with status epilepticus is an uncommon but serious presentation. While JME typically responds well to appropriate medications, some patients have drug-resistant forms, and status epilepticus in this context is a medical emergency. Treatment-resistant JME may indicate incorrect medication choice (some antiepileptics worsen myoclonic seizures) rather than true pharmacoresistance.
Documentation Requirements
- ✓Confirmed JME diagnosis
- ✓Documentation of intractability with failed medication trials
- ✓Active status epilepticus during the encounter
- ✓Complete medication history including agents tried and failed
- ✓Assessment for medication appropriateness (avoiding seizure-worsening drugs)
- ✓Emergency interventions provided