Z97.16
BillablePresence of artificial legs, bilateral (complete) (partial)
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is Z97.16 an HCC code?
Yes. Z97.16 maps to Amputation Status, Lower Limb/Amputation Complications under the CMS-HCC V28 risk adjustment model.
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 Z97.16
For Z97.16 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 Z97.16 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
Z97.16 is the ICD-10-CM diagnosis code for presence of artificial legs, bilateral (complete) (partial). A patient has artificial leg prosthetics on both sides (bilateral), which may be complete or partial replacements. Z97.16 sits in the ICD-10-CM chapter for factors influencing health status and contact with health services (z00-z99), within the section covering persons with potential health hazards related to family and personal history and certain conditions influencing health status (z77-z99).
Under the CMS-HCC V28 risk adjustment model, Z97.16 maps to Amputation Status, Lower Limb/Amputation Complications (HCC 409) with a community, non-dual, aged base RAF weight of 0.350. Z97.16 was not retained as a payment HCC under the older V24 model, so V28 introduced or recategorized it during the 2024–2026 phase-in. 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.
This code specifically indicates bilateral leg prosthetics; do not use Z97.13 and Z97.14 together when Z97.16 applies. Because Z97.16 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 Z97.16 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
Clinical Significance
This code indicates the presence of bilateral leg prosthetics, representing adaptation to major bilateral limb loss with severe impact on mobility and independence. These patients have the highest complexity prosthetic care needs and require extensive rehabilitation and ongoing medical management.
Documentation Requirements
- ✓Confirmation of bilateral artificial leg prosthetics
- ✓Level of amputation for each leg
- ✓Type of prosthetic devices (matching or different)
- ✓Functional status with bilateral prosthetics
- ✓Gait training and mobility status
- ✓Bilateral fitting and adjustment needs
- ✓Wheelchair use in addition to prosthetics
- ✓Complex rehabilitation requirements