Question 1

What is ICD-10 code D49.3?

Accepted Answer

D49.3 is the ICD-10-CM diagnosis code for neoplasm of unspecified behavior of breast. A tumor or growth of unknown behavior found in breast tissue. D49.3 sits in the ICD-10-CM chapter for neoplasms (c00-d49), within the section covering neoplasms of unspecified behavior (d49).

D49.3 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.

Specify laterality (right or left breast) and location within the breast if documented in the medical record.

Question 2

Is D49.3 an HCC code?

Accepted Answer

No. D49.3 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 D49.3 billable?

Accepted Answer

Yes. D49.3 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. D49.3 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 D49.3?

Accepted Answer

D49.3 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 D49.3 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 D49.3?

Accepted Answer

Specify laterality (right or left breast) and location within the breast if documented in the medical record Obtain biopsy results or imaging findings to determine if the lesion should be classified as benign (D24) or malignant (C50)

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D49.3

Is D49.3 an HCC code?

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D49.3 ICD-10-CM Code: Neoplasm of unspecified behavior of breast

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D49.3

Is D49.3 an HCC code?

Get the V28 RAF + MEAT cheat sheet

What This Code Means

Coding Tips

Excludes 1, Do NOT code together

Child Codes

Code Hierarchy

Work D49.3 in HCC Buddy