Hospice ICD-10 coding: principal diagnosis rules and common codes

What can be the principal hospice diagnosis?

The principal diagnosis is the one most contributory to the terminal prognosis (Claims Processing Manual, ch. 11, §30.3). The ICD-10-CM guidelines apply their principal diagnosis rules to hospice at every level of care. CMS returns the claim to the hospice when the principal diagnosis is:

• Debility or failure to thrive. R54, age-related physical debility (which includes frailty and old age), and R62.7, adult failure to thrive. CMS has returned these claims since October 1, 2014.
• An unspecified dementia code. Category F03, unspecified dementia, for example F03.90. Code the cause of the dementia when it is known.
• A Z code. Z codes describe status or encounters, such as Z51.5, encounter for palliative care, or Z66, do not resuscitate. They cannot be the principal diagnosis on a hospice claim.
• A code that cannot be principal under ICD-10-CM conventions. Manifestation codes titled "in diseases classified elsewhere", such as F02.-, dementia in other diseases classified elsewhere, must follow the code for the underlying condition.

Can a symptom code (R code) be the principal diagnosis?

Usually not. The ICD-10-CM guidelines say codes for symptoms, signs and ill-defined conditions (Chapter 18, R00 to R99) are not used as the principal diagnosis when a related definitive diagnosis has been established (Section II.A). For hospice, R54 and R62.7 are named in the CMS manual and returned outright.

For a frail patient in decline, the certifying physician identifies the condition that contributes most to the prognosis, such as dementia, heart failure or chronic lung disease, and reports weight loss, debility and the other conditions as additional diagnoses. See adult failure to thrive and debility.

Which other diagnoses go on the hospice claim?

The hospice reports all diagnoses identified in the initial and comprehensive assessments, whether related or unrelated to the terminal prognosis. That includes mental health disorders and any condition that affects the plan of care (Claims Processing Manual, ch. 11, §30.3).

Whether a condition is related to the terminal illness is a clinical decision the hospice makes for each patient. For elections on or after October 1, 2026, the hospice lists the conditions, items, services and drugs it has decided are unrelated, with the reasons, in the election statement addendum.

Common hospice diagnoses with example ICD-10-CM codes

Each code below is a valid billable code in the FY2027 ICD-10-CM code set (October 1, 2026 to September 30, 2027) and was also valid in FY2026. Pick the code that matches the physician's documentation. These are examples, not a complete list.

Do not code from this table alone. Check the Tabular List for each code's code-first, use-additional-code and excludes notes, and check the current hospice LCD for the clinical findings that support the prognosis.

How the dementia coding rule works

Dementia is often coded in two parts: the disease that causes it, and the dementia itself. ICD-10-CM calls this the etiology and manifestation convention. The cause, such as Alzheimer's disease (G30.-), carries a use-additional-code note, and the dementia code in category F02 carries a code-first note. Codes with "in diseases classified elsewhere" in the title are never the principal or first-listed diagnosis (guideline I.A.13).

So a patient with late-onset Alzheimer's disease and severe dementia with agitation is coded G30.1, then F02.C11. Coding F02.C11 or F03.90 as principal would send the claim back. The F02 and F03 codes show severity (unspecified, mild, moderate or severe) and any behavioral, psychotic, mood or anxiety disturbance, based only on the provider's documentation (guideline I.C.5.d).

Common questions about hospice ICD-10 coding

Related guides

The eligibility guidelines by diagnosis, adult failure to thrive and debility, the election statement and addendum, and short definitions in the hospice glossary.