I50.42 ICD-10-CM Code: Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.42 maps to CMS-HCC V28 226 (RAF 0.360). Documentation must support MEAT. MEAT criteria · RAF calculator · HCC coding software
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FY 2026 Apr update / Diseases of the circulatory system (I00-I99) / Other forms of heart disease (I30-I5A)
I50.42
Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidanceChronic combined systolic (congestive) and diastolic (congestive) heart failure
A long-term condition where the heart has both reduced pumping ability and stiffness, preventing effective blood circulation and causing persistent symptoms.
Buddy Insight
Chronic combined systolic and diastolic congestive heart failure indicates longstanding dual ventricular dysfunction requiring comprehensive ongoing management.
CMS-HCC V28
MappedHCC 226
RAF 0.360
CMS-HCC V24
MappedHCC 85
RAF 0.331
ACA/HHS
MappedHCC 130
Varies by metal level
ESRD/PACE
MappedHCC 85
RAF 0.063
RXHCC
MappedHCC 186
RAF 0.110
Code Book Path
Inclusion Terms
Official- Combined systolic and diastolic left ventricular heart failure
- Heart failure with reduced ejection fraction and diastolic dysfunction
Excludes 2
OfficialICD-10-CM does not list Excludes 2 notes for I50.42 in this effective period.
Related Child Codes
Includes
OfficialICD-10-CM does not list Includes notes for I50.42 in this effective period.
Excludes 1
OfficialICD-10-CM does not list Excludes 1 notes for I50.42 in this effective period.
Code First
OfficialICD-10-CM does not list Code First sequencing instructions for I50.42 in this effective period.
Use Additional
OfficialICD-10-CM does not list Use Additional Code instructions for I50.42 in this effective period.
Code Also
Official- end stage heart failure, if applicable (I50.84)
Buddy Documentation Tip
MEAT Support
Audit Caution
Common Mistakes
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 I50.42 an HCC code?
Yes. I50.42 (Chronic combined systolic (congestive) and diastolic (congestive) heart failure) maps to Heart Failure, Except End Stage and Acute under the CMS-HCC V28 risk adjustment model (and Congestive Heart Failure under V24), with a community non-dual aged RAF of 0.360. It is billable for payment year 2026.
Coder answer: I50.42 is billable and maps to V28 HCC 226, Heart Failure, Except End Stage and Acute. Open it in the Code Book for the tabular path, RAF, and MEAT checklist.
- Code
- I50.42
- Description
- Chronic combined systolic (congestive) and diastolic (congestive) heart failure
- HCC (V28)
- HCC 226 — Heart Failure, Except End Stage and Acute
- RAF
- 0.360
- 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 I50.42 in the Code Book — tabular path, V28 RAF, and MEAT checklist →
MEAT Criteria for I50.42
For I50.42 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 I50.42 during that encounter, not just copy-forwarded from a problem list.
Coder workflow notes
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What This Code Means
I50.42 is the ICD-10-CM diagnosis code for chronic combined systolic (congestive) and diastolic (congestive) heart failure. A long-term condition where the heart has both reduced pumping ability and stiffness, preventing effective blood circulation and causing persistent symptoms. I50.42 sits in the ICD-10-CM chapter for diseases of the circulatory system (i00-i99), within the section covering other forms of heart disease (i30-i5a).
Under the CMS-HCC V28 risk adjustment model, I50.42 maps to Heart Failure, Except End Stage and Acute (HCC 226) with a community, non-dual, aged base RAF weight of 0.360. Under the older CMS-HCC V24 model, I50.42 maps to Congestive Heart Failure (HCC 85) with a community, non-dual, aged base RAF weight of 0.331. 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.
Provider must document combined systolic and diastolic HF, chronic. This code applies when both dysfunction types are charted, reduced EF with documented diastolic dysfunction, or a cardiology note explicitly naming mixed HF. Because I50.42 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 I50.42 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Provider must document combined systolic and diastolic HF, chronic. This code applies when both dysfunction types are charted, reduced EF with documented diastolic dysfunction, or a cardiology note explicitly naming mixed HF.
- •Do not use I50.42 when only one dysfunction type is documented. Systolic-only is I50.2x; diastolic-only is I50.3x. Combined HF requires both documented.
- •V28 HCC 226 at RAF 0.36. Clinically important subtype but shares the HCC weight with other I50 codes.
Clinical Significance
Chronic combined systolic and diastolic congestive heart failure indicates longstanding dual ventricular dysfunction requiring comprehensive ongoing management. These patients typically have more advanced disease, lower quality of life, and higher mortality than those with isolated systolic or diastolic failure. Annual recapture is essential for reflecting disease complexity.
Documentation Requirements
- ✓Provider must document 'chronic' combined systolic and diastolic heart failure
- ✓Echocardiographic evidence of both reduced ejection fraction and diastolic filling abnormalities
- ✓Guideline-directed medical therapy addressing both components
- ✓Functional status assessment and New York Heart Association functional class
- ✓Absence of current acute exacerbation — if worsening, code I50.43 instead
- ✓Monitoring plan and follow-up schedule
Commonly Confused Codes
- •I50.43: Acute on chronic combined heart failure: use when chronic disease has acute exacerbation
- •I50.22: Chronic systolic heart failure: only systolic component documented
- •I50.32: Chronic diastolic heart failure: only diastolic component documented
- •I50.40: Unspecified combined heart failure: does not specify chronicity
- •I50.84: End stage heart failure: terminal heart failure, distinct from chronic combined