C25.4
BillableMalignant neoplasm of endocrine pancreas
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is C25.4 an HCC code?
Yes. C25.4 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 C25.4
For C25.4 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 C25.4 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
C25.4 is the ICD-10-CM diagnosis code for malignant neoplasm of endocrine pancreas. Cancer that develops in the endocrine pancreas, the hormone-producing cells (islet cells) that regulate blood sugar and other functions. C25.4 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, C25.4 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, C25.4 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.
These are neuroendocrine tumors (NETs) and are distinct from exocrine pancreatic cancers. Because C25.4 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 C25.4 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •These are neuroendocrine tumors (NETs) and are distinct from exocrine pancreatic cancers
- •Document whether the tumor is functional (producing hormones) or non-functional for complete clinical picture
Clinical Significance
Endocrine pancreatic cancers (pancreatic neuroendocrine tumors or PNETs) are biologically and clinically distinct from the more common exocrine pancreatic adenocarcinomas. They generally have a better prognosis but can be functional (hormone-secreting) or non-functional, each requiring different management approaches. Accurate coding distinguishes these patients for appropriate resource allocation.
Documentation Requirements
- ✓Pathology confirmation of neuroendocrine tumor (NET) with grade (G1, G2, G3)
- ✓Functional status — whether the tumor produces hormones (insulin, gastrin, glucagon, VIP, somatostatin)
- ✓Ki-67 proliferation index to determine tumor grade
- ✓Current treatment status and stage
- ✓Provider statement confirming endocrine pancreas as the primary site
Use Additional Code
- code to identify any functional activity.