M97.02XA ICD-10-CM Code: Periprosthetic fracture around internal prosthetic left hip joint, initial encounter
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FY 2026 Apr update / Diseases of the musculoskeletal system and connective tissue (M00-M99) / Periprosthetic fracture around internal prosthetic joint (M97)
M97.02XA
Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidancePeriprosthetic fracture around internal prosthetic left hip joint, initial encounter
Periprosthetic fracture around internal prosthetic left hip joint, initial encounter
CMS-HCC V28
MappedHCC 402
RAF 0.0
CMS-HCC V24
MappedHCC 170
RAF 0.451
ACA/HHS
00
RAF 0
ESRD/PACE
MappedHCC 170
RAF 0.0
RXHCC
00
RAF 0
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Code Book Path
Inclusion Terms
OfficialICD-10-CM does not list inclusion terms for M97.02XA in this effective period.
Excludes 2
OfficialICD-10-CM does not list Excludes 2 notes for M97.02XA in this effective period.
Related Child Codes
Includes
OfficialICD-10-CM does not list Includes notes for M97.02XA in this effective period.
Excludes 1
OfficialICD-10-CM does not list Excludes 1 notes for M97.02XA in this effective period.
Code First
OfficialICD-10-CM does not list Code First sequencing instructions for M97.02XA in this effective period.
Use Additional
OfficialICD-10-CM does not list Use Additional Code instructions for M97.02XA in this effective period.
Code Also
OfficialICD-10-CM does not list Code Also instructions for M97.02XA in this effective period.
Last updated: FY2026 ICD-10-CM Apr update, Apr 1, 2026 through Sep 30, 2026. CMS-HCC V28 is 100% phased in for payment year 2026.
Is M97.02XA an HCC code?
Yes. M97.02XA maps to Pathological Fractures under the CMS-HCC V28 risk adjustment model (and Hip Fracture/Dislocation 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 M97.02XA
For M97.02XAto 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 M97.02XA during that encounter, not just copy-forwarded from a problem list.
What This Code Means
M97.02XA is the ICD-10-CM diagnosis code for periprosthetic fracture around internal prosthetic left hip joint, initial encounter. M97.02XA sits in the ICD-10-CM chapter for diseases of the musculoskeletal system and connective tissue (m00-m99), within the section covering periprosthetic fracture around internal prosthetic joint (m97).
Under the CMS-HCC V28 risk adjustment model, M97.02XA maps to Pathological Fractures (HCC 402) with a community, non-dual, aged base RAF weight of 0.000. Under the older CMS-HCC V24 model, M97.02XA maps to Hip Fracture/Dislocation (HCC 170) with a community, non-dual, aged base RAF weight of 0.451. 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.
Coders should report M97.02XA only when the provider documentation supports the specific condition described, since more specific codes within the same hierarchy can capture additional clinical detail and may carry a higher RAF weight. Because M97.02XA 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 M97.02XA sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.