ICD-10 I43
Billable / Specific HCC v28: 85 CCCardiomyopathy in diseases classified elsewhere
About ICD-10-CM I43
ICD-10-CM code I43 represents Cardiomyopathy in diseases classified elsewhere. This is a billable/specific code in the Circulatory System chapter (block I43). The 2026 edition of ICD-10-CM I43 became effective on October 1, 2025.
Coding Tips for I43
Specialist guidance from the PayerReady Medical Coding Team. Specificity warnings, HCC capture rules, sequencing notes.
I43 is a CMS-HCC v28 risk-adjustment code (category 85). To count for the patient Risk Adjustment Factor (RAF), document the diagnosis with MEAT language each calendar year: Monitored, Evaluated, Assessed, Treated. A diagnosis on the problem list alone does not satisfy CMS RADV audit standards. Include the diagnosis in the assessment with current status and current treatment plan.
I43 is designated CC for MS-DRG grouping. On inpatient claims, this code can shift the DRG to the with-CC variant when documented as a present-on-admission secondary diagnosis. Hospital CDI programs flag CC opportunities during chart review. Failure to capture this code may leave 30 to 80 percent of the inpatient stay revenue unrealized.
Type 1 Excludes
Pure excludes, these codes can never be coded together with I43. The conditions are mutually exclusive (e.g., congenital vs acquired forms).
- cardiomyopathy (in):
- coxsackie (virus) (B33.24)
- diphtheria (A36.81)
- sarcoidosis (D86.85)
- tuberculosis (A18.84)
Coding Notes
Code First
- underlying disease, such as:
- amyloidosis (E85.-)
- glycogen storage disease (E74.0-)
- gout (M10.0-)
- thyrotoxicosis (E05.0-E05.9-)
Medicare Advantage HCC Impact
Capture this diagnosis annually for accurate risk adjustment. Missed HCC captures are the #1 revenue leak in Medicare Advantage risk programs.
Inpatient DRG Impact, CC
codes Cardiomyopathy in diseases classified elsewhere. As a Complication/Comorbidity (CC), this contributes to DRG severity adjustment when documented alongside the principal diagnosis.
Medicare LCD Coverage for I43
Local Coverage Determinations (LCDs) from CMS MACs that list I43 as a covered diagnosis.
Showing top 10 of 494 total . Click a CPT for full coverage scope.
Commercial Payer Coverage
Coverage policies from major commercial payers referencing I43.
1 Aetna
2 Cigna
5 Medicare
CPT Codes Commonly Billed with I43
Procedures frequently paired with this diagnosis based on PayerReady's Dx↔Px linkage data.
We don't have CPT pairings indexed for this specific code yet. Use the CPT search above to find common procedures, or check your payer's published medical policy for code-specific guidance.
Convert I43 to ICD-9-CM
Per CMS General Equivalence Mappings (GEMs), useful for legacy data review and historical claim analysis.
| ICD-10 | ICD-9 | Mapping Flags |
|---|---|---|
| I43 | 4258 | 10000 |
Flags format (5 digits): Approximate · No Map · Combination · Scenario · Choice List. Source: CMS 2017 GEMs (final version).
Codes Adjacent To I43
Other codes in section I30-I5A (Other forms of heart disease).
ICD-10 I43, Billing FAQ
Is ICD-10 code I43 billable? +
Yes, I43 is a billable ICD-10-CM code that can appear as a primary or secondary diagnosis on claims.
What codes are Type 1 Excludes for I43? +
Type 1 Excludes (never code together with I43): cardiomyopathy (in):; coxsackie (virus) (B33.24); diphtheria (A36.81)
Does I43 affect Medicare Advantage HCC risk adjustment? +
Yes. I43 maps to CMS-HCC v28 category 85. Capture this diagnosis annually for accurate Medicare Advantage risk score.
Is I43 a CC or MCC for inpatient DRG? +
Yes, this code is designated as CC. Documenting as a secondary diagnosis on inpatient claims can shift the DRG to a higher-weighted category.
What ICD-9 codes does I43 map to? +
Per CMS GEMs, I43 maps to ICD-9 codes: 4258. Useful for legacy data review and historical claim analysis.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on July 16, 2026.
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