Question 1

What is ICD-10 code F45.42?

Accepted Answer

F45.42 is the ICD-10-CM diagnosis code for pain disorder with related psychological factors. Pain in one or more body areas where both a medical condition and psychological factors play a significant role in the onset, severity, or maintenance of the pain. F45.42 sits in the ICD-10-CM chapter for mental, behavioral and neurodevelopmental disorders (f01-f99), within the section covering anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders (f40-f48).

F45.42 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.

Document both the medical condition and the psychological factors contributing to pain.

Question 2

Is F45.42 an HCC code?

Accepted Answer

No. F45.42 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 F45.42 billable?

Accepted Answer

Yes. F45.42 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. F45.42 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 F45.42?

Accepted Answer

F45.42 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 community model rewards F45.42 with a risk adjustment factor, it contributes zero to a Medicare Advantage beneficiary's V28/V24 community RAF score in either version. Coders should check whether provider documentation supports a more specific child code that does map to a community payment HCC.

Question 5

What should coders know when reporting F45.42?

Accepted Answer

Document both the medical condition and the psychological factors contributing to pain Use this code when psychological factors are important but not the sole cause of pain

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F45.42

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F45.42 ICD-10-CM Code: Pain disorder with related psychological factors

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F45.42

Is F45.42 an HCC code?

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What This Code Means

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Work F45.42 in HCC Buddy