Question 1

What is ICD-10 code A04.1?

Accepted Answer

A04.1 is the ICD-10-CM diagnosis code for enterotoxigenic escherichia coli infection. This is a bacterial infection caused by a specific type of E. coli bacteria that produces toxins affecting the intestines, typically causing diarrhea and abdominal discomfort. It is commonly acquired through contaminated food or water. A04.1 sits in the ICD-10-CM chapter for certain infectious and parasitic diseases (a00-b99), within the section covering intestinal infectious diseases (a00-a09).

A04.1 is a billable ICD-10-CM code but does not map to a payment HCC under the CMS-HCC V28, V24, ESRD, or RxHCC risk adjustment models. It can be reported on Medicare Advantage encounter data submissions but it does not contribute to a beneficiary's RAF score and therefore does not affect risk-adjusted payments to the plan.

Verify documentation specifies enterotoxigenic E. coli (ETEC) rather than other pathogenic E. coli strains, as different codes apply to different types.

Question 2

Is A04.1 an HCC code?

Accepted Answer

No. A04.1 is a billable ICD-10-CM code but does not map to any payment HCC category under the CMS-HCC V28, V24, ESRD, or RxHCC risk adjustment models. It can still be reported on Medicare Advantage encounter data submissions, but it does not contribute to the beneficiary's Risk Adjustment Factor (RAF) score and therefore does not affect the risk-adjusted capitation payment to the plan. V28 reached 100% phase-in for payment year 2026.

Question 3

Is A04.1 billable?

Accepted Answer

Yes. A04.1 is a billable ICD-10-CM code that can be reported on professional and institutional claims as a primary or secondary diagnosis when the provider documentation supports the specific condition described. Billable codes in ICD-10-CM are coded to the highest level of specificity available for the documented diagnosis. A04.1 is current for fiscal year 2026 and remains in the active CMS ICD-10-CM code set published by the National Center for Health Statistics.

Question 4

What is the V28 vs V24 difference for A04.1?

Accepted Answer

A04.1 does not map to a payment HCC under either the CMS-HCC V28 risk adjustment model or the older V24 model. V28 reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition. Because neither model rewards A04.1 with a risk adjustment factor, it contributes zero to a Medicare Advantage beneficiary's RAF score in either version. Coders should check whether provider documentation supports a more specific child code that does map to a payment HCC.

Question 5

What should coders know when reporting A04.1?

Accepted Answer

Verify documentation specifies enterotoxigenic E. coli (ETEC) rather than other pathogenic E. coli strains, as different codes apply to different types Document the site of infection (intestinal) and any associated symptoms like diarrhea to support medical necessity and severity assessment

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A04.1

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A04.1 ICD-10-CM Code: Enterotoxigenic Escherichia coli infection

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A04.1

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