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I09.81 ICD-10-CM Code: Rheumatic heart failure

Billing Status: YES. This is a valid, specific, and billable ICD-10-CM reference.

Coding at a Glance

Tabular directives
1 use-additional code
Risk adjustment
CMS-HCC V28: 1 category · CMS-HCC V22 category 85 · RxHCC V08 category 186

Inpatient Payment Groups (MS-DRG)

Potential MS-DRG participation — not a DRG assignment.

MS-DRGs this diagnosis helps define, as principal or secondary, per the CMS ICD-10-CM/PCS MS-DRG Definitions Manual v43, Appendix B.

  • MS-DRG 291 — HEART FAILURE AND SHOCK WITH MCC (MDC 05)
  • MS-DRG 292 — HEART FAILURE AND SHOCK WITH CC (MDC 05)
  • MS-DRG 293 — HEART FAILURE AND SHOCK WITHOUT CC/MCC (MDC 05)
  • MS-DRG 791 — PREMATURITY WITH MAJOR PROBLEMS (MDC 15)
  • MS-DRG 793 — FULL TERM NEONATE WITH MAJOR PROBLEMS (MDC 15)

A diagnosis appearing in a group's logic does not by itself determine the DRG assigned to a stay; the grouper uses the full claim.

Risk Adjustment (CMS-HCC)

Payment categories this diagnosis maps to under CMS-HCC V28, payment year 2026.

  • HCC 226 — Heart Failure, Except End-Stage and Acute (supersedes HCC 227)

Other models: CMS-HCC V22 HCC 85 · RxHCC V08 HCC 186

Risk scores depend on the enrollee's full accepted diagnosis set and segment; a category mapping alone does not determine payment.

Coding instructions

Official Tabular Instructional Notes: the inclusion, exclusion and sequencing notes published for I09.81 in the official ICD-10-CM tabular list, quoted as published.

Source: CMS/CDC — ICD-10-CM Tabular ListRelease: FY2026Effective: October 1, 2025

Use Additional Code

Supplementary codes the tabular list directs you to add.

  • Use additional code to identify type of heart failure (I50.-)

Coder workflow for I09.81

MedCoder structured workflow — derived from this code’s own official record

Documentation check

The provider’s diagnostic statement
Codes are assigned from the provider’s documented diagnosis, not from clinical criteria, test values or a medication list (Guidelines I.A.19).
The conditions the Use Additional Code note names
Reported with this code when documented; a conditional instruction (“if applicable”, “if known”) applies only when the record supports it.

Official instructions as workflow

  • Use Additional Code — after identifying I09.81(1 note)

    Coding workflow: Check whether the documentation supports the additional code(s) the note names, and report them with I09.81 when it does. Where the instruction is conditional (“if applicable”, “if known”), it applies only when the record documents the condition.

    ReviewI50

    See the official tabular notes · Guidelines I.A.13

Coding decision scenarios

Pattern scenarios for this code’s structure — decision rules, not clinical cases

Documentation: A condition the Use Additional Code note names is documented.

Coding question: Is a second code reported with I09.81?

Path: Review the Use Additional Code note and the code it names.

Reason: The additional code is reported when the record documents the condition; a conditional instruction applies only when its condition is met (Guidelines I.A.13).

ReviewI50

Every row is derived from this code’s own record — its title, tabular notes, 7th-character family and same-category siblings — with fixed MedCoder wording; nothing is inferred about a patient. The official notes and guideline text are in the sections each row links to, and they control.

Code Overview

Rheumatic heart failure is a billable ICD-10-CM diagnosis code (I09.81).

MedCoder summary Summary composed by MedCoder from this code's official ICD-10-CM record. The tabular instructional notes themselves appear verbatim below.

Indexed Clinical Terms (6)

Official source data — entries quoted as published, in the Index’s own lookup phrasing

Clinical term phrases from the official ICD-10-CM Index to Diseases and Injuries that map to this code. These are alphabetic-index entries shown as the Index writes them — lookup phrasing, not necessarily the wording of a final diagnosis.

Verify Before Coding

  • CC as a secondary diagnosis (FY2026). Can raise the stay's MS-DRG severity tier.

From the code registry, the Medicare Code Editor, and the MS-DRG Definitions Manual. Check it against a full claim in Claim Check.

Relationships & Classification

MedCoder structured relationships — computed from published CMS and AHRQ datasets

Other codes that name I09.81 or its code family, from the CMS ICD-10-CM tabular instructional notes. Tabular-note edges are stored at the code family level that carries each note.

Referenced by 1 Excludes1 note: I01 — Rheumatic fever with heart involvement (via I09.-).

These codes’ tabular lists mark this diagnosis as mutually exclusive — not reported together unless the conditions are documented as unrelated.

Referenced by 1 Excludes2 note: I51 — Complications and ill-defined descriptions of heart disease (via I09.-).

These codes’ tabular lists name this diagnosis as distinct — both may be reported when both are documented.

Referenced by 1 Code First instruction: I50 — Heart failure.

Each of these codes carries a Code First note naming this condition — when that code is reported, THIS code is sequenced first, ahead of it.

MS-DRG Grouper Relationships (FY2026)

Potential MS-DRG participation — not a DRG assignment.

FY2026 MS-DRG: CC — Complication or Comorbidity. Reported as a secondary diagnosis, this code raises the stay's MS-DRG severity tier — except when the principal diagnosis is one of 33 clinically related codes on its CMS exclusion list.

Named in the grouper logic of 5 MS-DRGs: DRG 291 (MDC 05), DRG 292 (MDC 05), DRG 293 (MDC 05), DRG 791 (MDC 15), DRG 793 (MDC 15).

From the CMS MS-DRG Definitions Manual (Appendices B and C). Actual DRG assignment depends on the complete claim.

Clinical classification (AHRQ CCSR):CIR019 — Heart failure (default); CIR001 — Chronic rheumatic heart disease.

Clinical Classifications Software Refined (CCSR) for ICD-10-CM Diagnoses. Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality.

Related Codes

Same clinical process (MS-DRG)

Acts as CC — raises the severity of other admissions. CMS groups these diagnoses into one MS-DRG principal-diagnosis exclusion process — a CC/MCC on this list never raises severity when the principal diagnosis is also on it.

I09.9 — Rheumatic heart disease, unspecified, I11.0 — Hypertensive heart disease with heart failure, I27.841 — Fontan-associated lymphatic dysfunction, I27.848 — Other Fontan-associated condition, I27.849 — Fontan related circulation, unspecified, I50.1 — Left ventricular failure, unspecified, I50.20 — Unspecified systolic (congestive) heart failure, I50.21 — Acute systolic (congestive) heart failure, I50.22 — Chronic systolic (congestive) heart failure, I50.23 — Acute on chronic systolic (congestive) heart failure, I50.30 — Unspecified diastolic (congestive) heart failure, I50.31 — Acute diastolic (congestive) heart failure, I50.32 — Chronic diastolic (congestive) heart failure, I50.33 — Acute on chronic diastolic (congestive) heart failure, I50.40 — Unspecified combined systolic (congestive) and diastolic (congestive) heart failure, I50.41 — Acute combined systolic (congestive) and diastolic (congestive) heart failure, I50.42 — Chronic combined systolic (congestive) and diastolic (congestive) heart failure, I50.43 — Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, I50.810 — Right heart failure, unspecified, I50.811 — Acute right heart failure, +12 more

Same CMS-HCC risk category (V28)

CMS maps these diagnoses to the same Hierarchical Condition Category (Heart Failure, Except End-Stage and Acute) for risk-adjusted payment.

I11.0 — Hypertensive heart disease with heart failure, I13.0 — Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, I13.2 — Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease, I27.0 — Primary pulmonary hypertension, I27.1 — Kyphoscoliotic heart disease, I27.20 — Pulmonary hypertension, unspecified, I27.21 — Secondary pulmonary arterial hypertension, I27.22 — Pulmonary hypertension due to left heart disease, I27.23 — Pulmonary hypertension due to lung diseases and hypoxia, I27.24 — Chronic thromboembolic pulmonary hypertension, I27.29 — Other secondary pulmonary hypertension, I27.81 — Cor pulmonale (chronic), I27.83 — Eisenmenger's syndrome, I27.89 — Other specified pulmonary heart diseases, I27.9 — Pulmonary heart disease, unspecified, I28.0 — Arteriovenous fistula of pulmonary vessels, I28.1 — Aneurysm of pulmonary artery, I28.8 — Other diseases of pulmonary vessels, I28.9 — Disease of pulmonary vessels, unspecified, I50.1 — Left ventricular failure, unspecified, +13 more

Related risk categories

These categories interact through CMS's HCC hierarchy — one can suppress the other's risk-adjustment weight when both are present on a claim.

Heart Failure with Heart Assist Device/Artificial Heart, Acute on Chronic Heart Failure, Acute Heart Failure (Excludes Acute on Chronic), Cardiomyopathy/Myocarditis

Same clinical category (CCSR)

AHRQ's Clinical Classifications Software groups these diagnoses under the same clinical categories (Heart failure, Chronic rheumatic heart disease).

I07.9 — Rheumatic tricuspid valve disease, unspecified, I08.0 — Rheumatic disorders of both mitral and aortic valves, I08.1 — Rheumatic disorders of both mitral and tricuspid valves, I08.2 — Rheumatic disorders of both aortic and tricuspid valves, I08.3 — Combined rheumatic disorders of mitral, aortic and tricuspid valves, I08.8 — Other rheumatic multiple valve diseases, I08.9 — Rheumatic multiple valve disease, unspecified, I09.0 — Rheumatic myocarditis, I09.1 — Rheumatic diseases of endocardium, valve unspecified, I09.2 — Chronic rheumatic pericarditis, I09.89 — Other specified rheumatic heart diseases, I09.9 — Rheumatic heart disease, unspecified, I11.0 — Hypertensive heart disease with heart failure, I13.0 — Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, I13.2 — Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease, I50.1 — Left ventricular failure, unspecified, I50.20 — Unspecified systolic (congestive) heart failure, I50.21 — Acute systolic (congestive) heart failure, I50.22 — Chronic systolic (congestive) heart failure, I50.23 — Acute on chronic systolic (congestive) heart failure, +40 more

Same Index main term, other category

The ICD-10-CM Index to Diseases and Injuries files this code under the main terms “Failure, failed”, “Fever”; these codes share that main term but sit in a different category of the Tabular List.

I01 — Rheumatic fever with heart involvement (rheumatic, active with heart involvement), I01.8 — Other acute rheumatic heart disease (heart, congestive, rheumatic, active or acute), I02.0 — Rheumatic chorea with heart involvement (ventricular, left, rheumatic, active or acute, with chorea), I02.9 — Rheumatic chorea without heart involvement (rheumatic, with central nervous system involvement), I05.8 — Other rheumatic mitral valve diseases (mitral), I05.9 — Rheumatic mitral valve disease, unspecified (rheumatic, inactive or quiescent with, endocarditis, mitral), I06.8 — Other rheumatic aortic valve diseases (aortic, rheumatic), I06.9 — Rheumatic aortic valve disease, unspecified (rheumatic, inactive or quiescent with, endocarditis, aortic), I07.8 — Other rheumatic tricuspid valve diseases (rheumatic, inactive or quiescent with, endocarditis, tricuspid), I08.0 — Rheumatic disorders of both mitral and aortic valves (rheumatic, inactive or quiescent with, endocarditis, aortic, with mitraldisease), I12.0 — Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease (renal, end stage, due to hypertension), I13.2 — Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease (cardiorenal, hypertensive), I35.8 — Other nonrheumatic aortic valve disorders (aortic), I50.1 — Left ventricular failure, unspecified (ventricular, left), I50.20 — Unspecified systolic (congestive) heart failure (Note: heart failure stages A, B, C, and D are based on the American College of Cardiology and American Heart Association stages of heart failure, which complement and should not be confused with the New York Heart Association Classification of Heart Failure, into Class I, Class II, Class III, and Class IV, systolic), I50.21 — Acute systolic (congestive) heart failure (Note: heart failure stages A, B, C, and D are based on the American College of Cardiology and American Heart Association stages of heart failure, which complement and should not be confused with the New York Heart Association Classification of Heart Failure, into Class I, Class II, Class III, and Class IV, systolic, acute), I50.22 — Chronic systolic (congestive) heart failure (Note: heart failure stages A, B, C, and D are based on the American College of Cardiology and American Heart Association stages of heart failure, which complement and should not be confused with the New York Heart Association Classification of Heart Failure, into Class I, Class II, Class III, and Class IV, systolic, chronic), I50.23 — Acute on chronic systolic (congestive) heart failure (heart, with, decompensation, systolic), I50.30 — Unspecified diastolic (congestive) heart failure (heart, diastolic), I50.31 — Acute diastolic (congestive) heart failure (heart, diastolic, acute), +253 more

Lab tests where this diagnosis supports Medicare coverage (NCD)

Medicare's National Coverage Determination (NCD) program lists this diagnosis as medical justification for these lab tests.

Prothrombin Time Test and INR (PT/INR)

Contextual Map

Every relationship of I09.81 in one view: hierarchy, official tabular instructions in both directions, clinical classification, risk adjustment, MS-DRG participation, index terms and change history — each edge carrying the CMS source it derives from.

Run I09.81 with these 3 related codes in Claim Check

Hierarchy

Use Additional Code

  • I50 — Heart failure[Use Additional Code]: “code to identify type of heart failure (I50.-)”— CMS ICD-10-CM tabular instructional notes · icd10cm-fy2026

Referenced by Excludes1 notes

  • I01 — Rheumatic fever with heart involvement[Excludes1](via I09.-): “chronic diseases of rheumatic origin (I05-I09) unless rheumatic fever is also present or there is evidence of reactivation or activity of the rheumatic process.”— CMS ICD-10-CM tabular instructional notes · icd10cm-fy2026

Referenced by Excludes2 notes

Referenced by Code First instructions

  • I50 — Heart failure[Code First]: “rheumatic heart failure (I09.81)”— CMS ICD-10-CM tabular instructional notes · icd10cm-fy2026

Clinical classification (CCSR)

Risk adjustment (CMS-HCC)

  • HCC 226 — Heart Failure, Except End-Stage and Acute [CMS-HCC]: “Heart Failure, Except End-Stage and Acute — supersedes HCC 227 (Cardiomyopathy/Myocarditis)”— CMS-HCC V28 · 2026

MS-DRG Grouper

MDC crossing

  • MDC 05 — Diseases and Disorders of the Circulatory System[MDC crossing]: “Diseases and Disorders of the Circulatory System — the grouper's crossing between diagnoses and procedures: a principal diagnosis sets the MDC, and same-MDC procedures move the stay to its surgical DRGs. 17,209 same-MDC procedures group here; browse them on the MDC page.”— CMS MS-DRG Definitions Manual · FY2026
  • MDC 15 — Newborns and Other Neonates with Conditions Originating in Perinatal Period[MDC crossing]: “Newborns and Other Neonates with Conditions Originating in Perinatal Period — the grouper's crossing between diagnoses and procedures: a principal diagnosis sets the MDC, and same-MDC procedures move the stay to its surgical DRGs.”— CMS MS-DRG Definitions Manual · FY2026

Index entries

  • Failure, failed, heart (acute) (senile) (sudden), congestive, rheumatic (chronic) (inactive) (with chorea)[Index term]— CMS ICD-10-CM Index to Diseases and Injuries · icd10cm-fy2026
  • Failure, failed, heart (acute) (senile) (sudden), congestive, with rheumatic fever (conditions in I00), inactive or quiescent (with chorea)[Index term]— CMS ICD-10-CM Index to Diseases and Injuries · icd10cm-fy2026
  • Failure, failed, ventricular, left, rheumatic (chronic) (inactive) (with chorea)[Index term]— CMS ICD-10-CM Index to Diseases and Injuries · icd10cm-fy2026
  • Failure, failed, ventricular, left, with rheumatic fever (conditions in I00), inactive or quiescent (with chorea)[Index term]— CMS ICD-10-CM Index to Diseases and Injuries · icd10cm-fy2026
  • Fever (inanition) (of unknown origin) (persistent) (with chills) (with rigor), rheumatic (active) (acute) (chronic) (subacute), inactive or quiescent with, heart failure (congestive) (conditions in category I50.)[Index term]— CMS ICD-10-CM Index to Diseases and Injuries · icd10cm-fy2026
  • Fever (inanition) (of unknown origin) (persistent) (with chills) (with rigor), rheumatic (active) (acute) (chronic) (subacute), inactive or quiescent with, left ventricular failure (conditions in I50.1-I50.4-)[Index term]— CMS ICD-10-CM Index to Diseases and Injuries · icd10cm-fy2026

Nearest codes

Change history

  • FY2016 — In the code set at ICD-10-CM adoption [Change history]— CMS release files (code change ledger) · icd10cm-fy2016

Sources for this page

Codes, titles, notes, index terms and mappings on this page are transcribed from the datasets below. Relationships MedCoder computed and text MedCoder wrote are labelled where they appear.

Code, title, tabular notes and index terms Official source data
CMS/CDC ICD-10-CM FY2026 tabular list, index and tables, effective October 1, 2025 Release, file and checksum · Publisher’s page
Claim edits Official source data
CMS Definitions of Medicare Code Edits — v43.1 (April 2026) Release, file and checksum · Publisher’s page
Inpatient payment groups Official source data
CMS MS-DRG Definitions Manual (incl. Appendix B diagnosis index, Appendix C CC/MCC list, Appendix E procedure index) and IPPS Final Rule tables — v43 Release, file and checksum · Publisher’s page
Risk adjustment Official source data
2026 Mid-Year Final ICD-10 Mappings + Model Software (cms.gov/files/zip/2026-midyear-final-icd-10-mappings.zip, 2026-midyear-final-model-software.zip) — CMS-HCC V28, PY2026 mid-year final release Release, file and checksum · Publisher’s page
Change history and date-of-service validity Official source data
CMS ICD-10-CM release addenda, ingested release by release into the change ledger Release, file and checksum · Publisher’s page
Comparisons, relationships and the contextual map MedCoder structured relationship
Computed by MedCoder from the tabular notes and tables above; every derived relationship is marked as derived where it appears
Summary and FAQ answers MedCoder explanation
Written by MedCoder to explain the sources above: drafted with AI assistance, checked by a person against the release files, and labelled as MedCoder text where it appears. Not official text.

Labels on this page: Official source data · MedCoder structured relationship · MedCoder explanation. How to read the labels · All data sources and release dates

Cite this page

Reference this page in a research guide, syllabus or article. The release is included because code content changes each year.

MedCoder.ai. "I09.81 — Rheumatic heart failure." ICD-10-CM FY2026. https://medcoder.ai/icd10/code/i09.81-rheumatic-heart-failure

Change history

  • FY2016 — October 1, 2015
    In the code set at ICD-10-CM adoption
    Rheumatic heart failure

No changes since FY2016 — additions, deletions, description changes and billable-status changes are tracked through FY2027 (effective October 1, 2026), and none are recorded for this code. Note changes are tracked from FY2027 only.

Nearest Codes in This Family

Official ICD-10-CM classifications closest to I09.81 in its code family, with their registry titles.

View all codes in the I09 family