C25.3
BillableMalignant neoplasm of pancreatic duct
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is C25.3 an HCC code?
Yes. C25.3 maps to Lung and Other Severe Cancers under the CMS-HCC V28 risk adjustment model (and Lung and Other Severe Cancers under V24).
HCC Category Mapping
RAF weights shown are the community, non-dual, aged base weights from the CMS risk adjustment model file. Actual per-patient RAF contribution depends on member segment, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains in use during the transition and for historical data.
MEAT Criteria for C25.3
For C25.3 to count as a valid HCC diagnosis in a given encounter, the provider's documentation must show MEAT: Monitor, Evaluate, Assess, or Treat. A diagnosis from a prior year does not carry forward automatically — it has to be re-documented and supported each calendar year.
- MMonitor: signs, symptoms, disease progression, or lab trending documented in the note
- EEvaluate: test results, medication response, or physical findings reviewed by the provider
- AAssess: explicit mention in the assessment or plan with acknowledgment of status
- TTreat: medication, referral, procedure, therapy, or counseling tied to the diagnosis
Only one of M/E/A/T is required to support the code, but the documentation must be specific enough to show that the provider actually addressed C25.3 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
C25.3 is the ICD-10-CM diagnosis code for malignant neoplasm of pancreatic duct. Cancer that originates in the pancreatic duct, the tube that carries digestive enzymes from the pancreas to the small intestine. C25.3 sits in the ICD-10-CM chapter for neoplasms (c00-d49), within the section covering malignant neoplasms of digestive organs (c15-c26).
Under the CMS-HCC V28 risk adjustment model, C25.3 maps to Lung and Other Severe Cancers (HCC 20) with a community, non-dual, aged base RAF weight of 0.000. Under the older V24 model, C25.3 mapped to the same category but with a base RAF weight of 0.973 — V28 recalibrated weights across the entire model. V28 is the CMS-HCC risk adjustment model that reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition.
Pancreatic duct cancers are typically adenocarcinomas and represent the majority of pancreatic cancers. Because C25.3 maps to a payment HCC, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's Medicare Advantage risk adjustment score. When documentation is ambiguous, coders should issue a provider query rather than assume the highest-specificity variant.
HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for C25.3 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Pancreatic duct cancers are typically adenocarcinomas and represent the majority of pancreatic cancers
- •Specify the location within the duct (head, body, or tail) if documented for more precise coding
Clinical Significance
Pancreatic duct adenocarcinoma is the most common and lethal form of pancreatic cancer, with a five-year survival rate under 12%. This code carries significant risk adjustment weight because patients require aggressive multimodal treatment including surgery, chemotherapy, and ongoing supportive care. Accurate capture is critical as these patients consume substantial healthcare resources.
Documentation Requirements
- ✓Pathology-confirmed malignancy with histological type (adenocarcinoma, mucinous, etc.)
- ✓Specific anatomical location within the pancreatic duct documented by imaging or surgical findings
- ✓Current treatment status (active treatment, surveillance, or palliative care)
- ✓Stage at diagnosis (TNM staging preferred)
- ✓Provider assessment confirming active malignancy vs. history of cancer
Commonly Confused Codes
- •C25.0 — Malignant neoplasm of head of pancreas: Most pancreatic duct cancers arise in the head; use C25.0 when the head is the documented primary site rather than the duct itself
- •C25.9 — Malignant neoplasm of pancreas, unspecified: Use when documentation does not specify the exact pancreatic site; query provider for specificity
- •D13.6 — Benign neoplasm of pancreas: Ensure malignancy is confirmed; do not code pre-malignant lesions like IPMN as malignant
- •K86.1 — Other chronic pancreatitis: Chronic pancreatitis can coexist or be confused with pancreatic cancer on imaging