ICD-10 L97.406
Billable / Specific HCC v28: 161 CCNon-pressure chronic ulcer of unspecified heel and midfoot with bone involvement without evidence of necrosis
About ICD-10-CM L97.406
ICD-10-CM code L97.406 represents Non-pressure chronic ulcer of unspecified heel and midfoot with bone involvement without evidence of necrosis. This is a billable/specific code in the Skin and Subcutaneous Tissue chapter (block L97). The 2026 edition of ICD-10-CM L97.406 became effective on October 1, 2025.
Coding Tips for L97.406
Specialist guidance from the PayerReady Medical Coding Team. Specificity warnings, HCC capture rules, sequencing notes.
L97.406 is a CMS-HCC v28 risk-adjustment code (category 161). 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.
L97.406 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.
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 Non-pressure chronic ulcer of unspecified heel and midfoot with bone involvement without evidence of necrosis. As a Complication/Comorbidity (CC), this contributes to DRG severity adjustment when documented alongside the principal diagnosis.
Medicare LCD Coverage for L97.406
Local Coverage Determinations (LCDs) from CMS MACs that list L97.406 as a covered diagnosis.
This doesn't mean the code isn't covered, it means no MAC has issued a Local Coverage Determination naming this specific code. Coverage may still apply under National Coverage Determinations or general medical-necessity rules.
Commercial Payer Coverage
Coverage policies from major commercial payers referencing L97.406.
Our payer policy database covers Aetna, Cigna, Anthem, BCBS, Humana, and Medicare Advantage plans, but L97.406 doesn't currently appear in any indexed policy. The code may still be covered under standard plan benefits.
CPT Codes Commonly Billed with L97.406
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.
Codes Adjacent To L97.406
Other codes in section L80-L99 (Other disorders of the skin and subcutaneous tissue).
ICD-10 L97.406, Billing FAQ
Is ICD-10 code L97.406 billable? +
Yes, L97.406 is a billable ICD-10-CM code that can appear as a primary or secondary diagnosis on claims.
Does L97.406 affect Medicare Advantage HCC risk adjustment? +
Yes. L97.406 maps to CMS-HCC v28 category 161. Capture this diagnosis annually for accurate Medicare Advantage risk score.
Is L97.406 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.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on May 31, 2026.
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