HCCHCC Category Descriptor / Example Diagnoses1HIV/AIDSHuman immunodeficiency virus [HIV] diseaseSepticemia, Sepsis, Systemic Inflammatory Response Syndrome/ShockGram-negative sepsis, unspecifiedSepsis, unspecified organismOpportunistic InfectionsPneumocystisMetastatic Cancer and Acute LeukemiaSecondary malignant neoplasm of unspecified siteLung and Other Severe CancersMalignant neoplasm of lower lobe, unspecified bronchus or lungMultiple myeloma in remissionOther Severe (e.g., Mesothelioma, Pancreas, Gallbladder, Liver, Stomach, Esophagus,Small intestine)Lymphoma and Other CancersSecondary and unspecified malignant neoplasm of lymph node, unspecifiedHodgkin lymphoma, unspecified, unspecified siteUnspecified B-cell lymphoma, unspecified siteNon-Hodgkin lymphoma, unspecified, unspecified siteOther (e.g., Brain, Endocrine, Ovary, Connective & Soft tissue, Peripheral nerves)Colorectal, Bladder, and Other CancersMalignant neoplasm of colon, unspecifiedMalignant neoplasm of bladder, unspecifiedMalignant neoplasm of unspecified kidney, except renal pelvisOther (e.g., Mouth, Tongue, Salivary Glands, Nasopharynx, Sinuses, Ear, Labia, Cervix)Breast, Prostate, and Other Cancers and TumorsMalignant neoplasm of unspecified site of unspecified female breastMalignant neoplasm of prostateMalignant neoplasm of endometriumOther (e.g., Penis, Eye, Musculoskeletal, Melanoma, Brain benign, Merkel cell, Carcinoid)Diabetes with Acute ComplicationsType 1 diabetes mellitus with ketoacidosis without comaType 2 diabetes mellitus with ketoacidosis without comaDiabetes with Chronic ComplicationsType 2 diabetes mellitus with diabetic chronic kidney diseaseType 2 diabetes mellitus with other circulatory complicationsDiabetes without ComplicationType 2 diabetes mellitus without complicationsProtein-Calorie MalnutritionMild protein-calorie malnutritionMorbid ObesityBody mass index (BMI) 40.0-44.9, adultClass 2 (BMI 35-39.9) severe obesity with serious comorbidity in adultOther Significant Endocrine and Metabolic DisordersHyperparathyroidism, unspecifiedSecondary hyperparathyroidism of renal originCategory2689101112171819212223 2020 Home Centered Care Institute12020

HCCCategory272829333435394046474851525455HCC Category Descriptor / Example DiagnosesEnd-Stage Liver DiseaseChronic hepatic failure without comaCirrhosis of LiverAlcoholic cirrhosis of liver without ascitesOther cirrhosis of liverChronic HepatitisChronic viral hepatitis, unspecifiedIntestinal Obstruction/PerforationFecal impactionChronic PancreatitisOther chronic pancreatitisInflammatory Bowel DiseaseCrohn's disease, unspecified, without complicationsOther ulcerative colitis without complicationsBone/Join/Muscle Infections/NecrosisArthritis due to other bacteria, unspecified jointDirect infection of unspec. joint in infectious and parasitic diseases classified elsewhereOther reactive arthropathies, unspecified siteReactive arthropathy, unspecifiedOsteomyelitis, unspecifiedRheumatoid Arthritis and Inflammatory Connective Tissue DiseaseOther rheumatoid arthritis with rheumatoid factor of unspecified siteRheumatoid arthritis with rheumatoid factor, unspecifiedRheumatoid arthritis without rheumatoid factor, unspecified siteSevere Hematological DisordersRefractory anemia, unspecifiedSickle-cell disease without crisisDisorders of ImmunityAntineoplastic chemotherapy induced pancytopeniaNeutropenia, unspecifiedCoagulation Defects and Other Specified Hematologic DisordersSickle-cell traitSenile PurpuraThrombocytopenia, unspecifiedDementia with ComplicationsAlzheimer’s disease with behavioral complicationsDementia without ComplicationAlzheimer’s disease without behavioral complicationsSubstance Use with Psychotic ComplicationsAlcohol dependence with withdrawal deliriumCannabis abuse with psychotic disorder, unspecifiedSubstance Use Disorder, Moderate/Severe, or Substance Use with ComplicationsAlcohol dependence, uncomplicatedAlcohol dependence, in remissionOpioid dependence, uncomplicatedOpioid dependence, in remission 2020 Home Centered Care Institute22019

HCCHCC Category Descriptor / Example Diagnoses56Substance Use Disorder, Mild, Except Alcohol and CannabisDrug abuse (can specify amphetamines, barbiturates, cocaine, hallucinogens, opioids, etc.)SchizophreniaSchizophrenia, unspecifiedReactive and Unspecified PsychosisAtypical psychosisUnspecified psychosis not due to a substance or known physiological conditionMajor Depressive, Bipolar, and Paranoid DisordersMajor depressive disorder, recurrent, mildPersonality DisordersPersonality disorder, Unspec. (others: Antisocial, Borderline, Manipulative, Narcissistic, etc.)QuadriplegiaQuadriplegia, unspecifiedFunctional quadriplegiaParaplegiaParaplegia, unspecifiedSpinal cord Disorders/ InjuriesMyelitis, unspecifiedUnspecified injury at unspecified level of thoracic spinal cord, subsequent encounterUnspecified injury at unspecified level of thoracic spinal cord, sequelaComplete lesion of unspecified level of lumbar spinal cord, sequelaIncomplete lesion of unspecified level of lumbar spinal cord, subsequent encounterAmyotrophic Lateral Sclerosis and Other Motor Neuron DiseaseAmyotrophic lateral sclerosisCerebral PalsyMyasthenia Gravis/Myoneural Disorders and Guillain-Barre Syndrome, Inflammatory andToxic 83Myasthenia gravis without (acute) exacerbationMyoneural disorder, unspecifiedMuscular DystrophyMultiple SclerosisParkinson’s and Huntington’s DiseasesParkinson's diseaseHuntington's diseaseSeizure Disorders and ConvulsionsOther seizuresEpilepsy, unspecified, not intractable, without status epilepticusComa, Brain Compression/Anoxic DamagePersistent vegetative stateAnoxic brain damage, not elsewhere classifiedRespirator Dependence/Tracheostomy StatusEncounter for attention to tracheostomyDependence on respirator [ventilator] statusRespiratory Arrest 2020 Home Centered Care Institute32019

HCCHCC Category Descriptor / Example Diagnoses84Cardio-Respiratory Failure and ShockChronic respiratory failure with hypoxiaChronic respiratory failure with hypercapniaCongestive Heart FailureHypertensive heart disease with heart failurePulmonary hypertension, unspecifiedCardiomyopathy, unspecifiedUnspecified systolic (congestive) heart failureChronic Systolic (congestive) heart failureUnspecified diastolic (congestive) heart failureHeart failure, unspecifiedAcute Myocardial InfarctionOther myocardial infarction typeUnstable Angina and Other Acute Ischemic Heart DiseaseUnstable anginaAngina PectorisAngina pectoris, unspecifiedStable anginaSpecified Heart ArrhythmiasUnspecified atrial fibrillationSick sinus syndromeSupraventricular TachycardiaCerebral HemorrhageOther nontraumatic subarachnoid hemorrhageOther nontraumatic intracerebral hemorrhageIschemic or Unspecified StrokeCerebral infarction due to thrombosis of unspecified carotid arteryCerebral infarction, unspecifiedHemiplegia/HemiparesisHemiplegia and hemiparesis following unspec. cerebrovascular disease affecting unspec. sideMonoplegia, Other Paralytic SyndromesMonoplegia, unspecified affecting unspecified sideAtherosclerosis of the Extremities with Ulceration or GangreneGas gangreneGangrene, not elsewhere classifiedVascular Disease with ComplicationsChronic pulmonary embolismEmbolism and thrombosis of arteries of extremities, unspecifiedVaricose veins of unspecified lower extremity with ulcer of unspecified siteVascular DiseaseAtherosclerosis of aortaAortic aneurysm of unspecified site, without rupturePeripheral vascular disease, unspecifiedPhlebitis & thrombophlebitis of unspecified deep vessels of unspecified lower extremityAcute embolism & thrombosis of unspecified deep veins of unspecified lower extremityChronic embolism & thrombosis of unspecified deep veins of unspecified lowerCategory858687889699100103104106107108 2020 Home Centered Care Institute42019

158159161162166167HCC Category Descriptor / Example DiagnosesCystic FibrosisCystic fibrosis, unspecifiedChronic Obstructive Pulmonary DiseaseEmphysema, unspecifiedChronic obstructive pulmonary disease, unspecifiedFibrosis of Lung and Other Chronic Lung DisordersPulmonary fibrosis, unspecifiedInterstitial pulmonary disease, unspecifiedAspiration and Specified Bacterial PneumoniasPneumonitis due to inhalation of food and vomitPneumococcal Pneumonia, Empyema, Lung AbscessPneumonia due to Streptococcus pneumoniaeAbscess of lung with pneumoniaProliferative Diabetic Retinopathy and Vitreous HemorrhageVitreous hemorrhage, unspecified eyeVitreous hemorrhage, bilateralExudative Macular DegenerationExudative age-related macular degeneration, unspecified eye, stage unspecifiedDialysis StatusOther mechanical complication of intraperitoneal dialysis catheter, sequelaAcute Renal FailureOther acute kidney failureChronic Kidney Disease, Stage 5Chronic Kidney Disease, Severe (Stage 4)Chronic kidney disease, Moderate (Stage 3)Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or BonePressure ulcer of unspecified site, stage 4Pressure Ulcer of Skin with Full Thickness Skin LossPressure ulcer of unspecified site, stage 3Pressure ulcer of unspecified site, unstageablePressure Ulcer of Skin with Partial Thickness Skin LossPressure ulcer of unspecified site, stage 2Chronic Ulcer of Skin, Except PressureNon-pressure chronic ulcer of skin of other sites with unspecified severitySevere Skin Burn or ConditionBurns involving 10-19% of body surface with 10-19% third degree burnsSevere Head InjuryUnspecified intracranial injury with loss of consciousness greater than 24 hours withreturn to pre-existing conscious level, initial encounterMajor Head InjuryUnspecified fracture of skull, sequelaUnspecified fracture of facial bones, sequelaDiffuse traumatic brain injury without loss of consciousness, sequelaDiffuse traumatic brain injury with loss of consciousness of unspecified duration, sequelaTraumatic subdural hemorrhage without loss of consciousness, sequelaTraumatic subarachnoid hemorrhage without loss of consciousness, sequela 2020 Home Centered Care Institute52019

HCCHCC Category Descriptor / Example Diagnoses169Vertebral Fractures without Spinal Cord InjuryCollapsed vertebra, not elsewhere classified, site unspec., initial encounter for fractureAge-related osteoporosis with current pathological fracture, vertebra(e), initialencounter for fractureFracture of neck, unspecified, initial encounterWedge compression fracture of unspecified thoracic vertebra, initial encounter forclosed fractureOther fracture of sacrum, initial encounter for closed fractureFracture of coccyx, initial encounter for closed fractureAge-related osteoporosis with current pathological fracture, vertebra(e), initialencounter for fractureHip Fracture/DislocationPathological fracture, unspecified femur, initial encounter for fracturePathological fracture in neoplastic disease, hip, unspecified, initial encounter for fractureUnspecified fracture of unspecified ilium, initial encounter for closed fractureUnspecified fracture of unspecified acetabulum, initial encounter for closed fractureUnspecified fracture of unspecified ischium, initial encounter for closed fractureFracture of other parts of pelvis, initial encounter for closed fractureTraumatic Amputations and ComplicationsPartial traumatic transmetacarpal amputation of unspecified hand, initial encounterPartial traumatic amputation of unspecified great toe, initial encounterComplications of Specified Implanted Device or GraftOther cystostomy complicationMajor Organ Transplant or Replacement StatusPresence of heart assist deviceArtificial Openings for Feeding or EliminationEncounter for attention to gastrostomyEncounter for attention to ileostomyEncounter for attention to colostomyEncounter for attention to cystostomyAmputation Status, Lower Limb/Amputation ComplicationsPhantom limb syndrome with painPartial traumatic amputation of unspecified great toe, subsequent encounterCategory1701731761861881892019 Z43.5G54.6S98.129D CMS uses a Hierarchical Condition Category (HCC) risk adjustment model to calculate patient risk scores to predict health care costs. Scores areused to adjust capitated payments for beneficiaries enrolled in Medicare Advantage and to determine expected costs in Medicare Shared SavingsPrograms (ACOs). Total Risk Adjustment Factor (RAF) Score Demographics Diagnoses Interactions Multiple HCC’s (4-10) Each year CMS publishes a "denominator" to convert risk scores into dollar amounts. The 2019 denominator is 9,367.34. Multiplying the riskscore by this denominator results in an estimated annual expenditure for a beneficiary. The diagnoses above often are “unspecified” only as examples. It is important to code to the highest level of specificity to achieve an accurate riskscore. All active diagnoses need to be documented and resubmitted each year. E/M documentation must support all submitted diagnoses. Proper documentation of each diagnosis must demonstrate the provider isMonitoring, Evaluating, Assessing/Addressing, or Treating (MEAT) the condition yearly. Useful Tool: Risk score calculator calculator/ Disclaimer: HCC Risk Adjustment values vary based on beneficiary demographics, RA model, specificity of the diagnosis reported, and change yearto year. Unspecified diagnosis code ranges are used throughout this resource simply as a reference point for you to then select the appropriatespecified code based on your patient’s conditions. HCC values listed are based on the 2020 CMS Alternative Payment Condition Count Model forcommunity non-dual aged beneficiaries. Risk adjustment weights may vary depending on the clinical circumstances. 2020 Home Centered Care

ICD-10 Code 56 Substance Use Disorder, Mild, Except Alcohol and Cannabis 0.329 Drug abuse (can specify amphetamines, barbiturates, cocaine, hallucinogens, opioids, etc.) F19.10 57 Schizophrenia 0.524 Schizophrenia, unspecified F20.9 58 Reacti