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G43.D1 ICD-10-CM Code: Abdominal migraine, intractable

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FY 2026 Apr update / Diseases of the nervous system (G00-G99) / Episodic and paroxysmal disorders (G40-G47)

G43.D1

Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidance

Abdominal migraine, intractable

Recurring episodes of abdominal pain occurring as a migraine variant that does not respond adequately to standard treatment methods.

Buddy the Bee presenting code insight

Buddy Insight

Abdominal migraine is a recurrent episodic condition characterized by midline abdominal pain, nausea, and vomiting, primarily affecting children but also occurring in adults.

CMS-HCC V28

0

0

RAF 0

CMS-HCC V24

0

0

RAF 0

ACA/HHS

0

0

RAF 0

ESRD/PACE

0

0

RAF 0

RXHCC

HCC 166

RAF 0.0

Code Trumping

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Code Book Path

Official
G43Migraine
G43.DAbdominal migraine
G43.D1Abdominal migraine, intractable

Inclusion Terms

Official
  • Abdominal migraine, with refractory migraine

Excludes 2

Official

ICD-10-CM does not list Excludes 2 notes for G43.D1 in this effective period.

Related Child Codes

Official
G43.D0Abdominal migraine, not intractable

Includes

Official

ICD-10-CM does not list Includes notes for G43.D1 in this effective period.

Excludes 1

Official

ICD-10-CM does not list Excludes 1 notes for G43.D1 in this effective period.

Code First

Official

ICD-10-CM does not list Code First sequencing instructions for G43.D1 in this effective period.

Use Additional

Official

ICD-10-CM does not list Use Additional Code instructions for G43.D1 in this effective period.

Code Also

Official

ICD-10-CM does not list Code Also instructions for G43.D1 in this effective period.

Buddy Documentation Tip

HCC Buddy guidance
Recurrent episodes of midline abdominal pain lasting 2-72 hours
Associated symptoms: nausea, vomiting, anorexia, pallor
Symptom-free intervals between episodes (complete return to baseline health)
Exclusion of gastrointestinal, renal, and metabolic causes of recurrent abdominal pain

MEAT Support

HCC Buddy guidance
Recurrent episodes of midline abdominal pain lasting 2-72 hours
Associated symptoms: nausea, vomiting, anorexia, pallor
Symptom-free intervals between episodes (complete return to baseline health)
Exclusion of gastrointestinal, renal, and metabolic causes of recurrent abdominal pain

Audit Caution

HCC Buddy guidance
Coding recurrent abdominal pain as generic R10.x when abdominal migraine is diagnosed — the specific code carries more clinical value
Not documenting exclusion of GI pathology, which is required before diagnosing abdominal migraine
Confusing abdominal migraine with cyclical vomiting syndrome — abdominal pain is the predominant feature in abdominal migraine
Applying this diagnosis without documenting the required episodic pattern with symptom-free intervals

Common Mistakes

HCC Buddy guidance
R10.9 (Unspecified abdominal pain) — non-specific symptom; use abdominal migraine code when diagnosis is established
K58.x (Irritable bowel syndrome) — chronic GI disorder, not episodic with complete symptom-free intervals
R11.15 (Cyclical vomiting syndrome, unrelated to migraine) — vomiting-predominant without abdominal pain focus
G43.A0-G43.A1 (Cyclical vomiting in migraine) — vomiting-predominant migraine variant vs. pain-predominant abdominal migraine

Last updated: FY2026 ICD-10-CM Apr update, Apr 1, 2026 through Sep 30, 2026. CMS-HCC V28 is 100% phased in for payment year 2026.

Is G43.D1 an HCC code?

No. G43.D1 is a billable ICD-10-CM code but does not map to any HCC category in V28, V24, ESRD, or RxHCC.

HCC Category Mapping

RxHCCHCC 166, Migraine
0.000

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.

Work G43.D1 in the Code Book — tabular path, V28 RAF, and MEAT checklist →

MEAT Criteria for G43.D1

For G43.D1to 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 G43.D1 during that encounter, not just copy-forwarded from a problem list.

Coder workflow notes

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What This Code Means

G43.D1 is the ICD-10-CM diagnosis code for abdominal migraine, intractable. Recurring episodes of abdominal pain occurring as a migraine variant that does not respond adequately to standard treatment methods. G43.D1 sits in the ICD-10-CM chapter for diseases of the nervous system (g00-g99), within the section covering episodic and paroxysmal disorders (g40-g47).

G43.D1 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.

Maps to RxHCC 166 (Severe Head Injury) with a RAF weight of 0.000 in the prescription drug model. No mapping to CMS-HCC V28 or V24 payment models. The RxHCC mapping captures pharmacy utilization for migraine preventive and abortive therapies. No hierarchies apply.

HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for G43.D1 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.

Coding Tips

  • •Document failed treatment attempts and the intractable nature of the condition
  • •Distinguish from other causes of recurrent abdominal pain by confirming migraine characteristics

Clinical Significance

Abdominal migraine is a recurrent episodic condition characterized by midline abdominal pain, nausea, and vomiting, primarily affecting children but also occurring in adults. It is recognized as a migraine variant and often precedes development of typical migraine headaches later in life. Accurate coding prevents unnecessary gastrointestinal workups and directs treatment toward migraine-specific therapies.

Documentation Requirements

  • ✓Recurrent episodes of midline abdominal pain lasting 2-72 hours
  • ✓Associated symptoms: nausea, vomiting, anorexia, pallor
  • ✓Symptom-free intervals between episodes (complete return to baseline health)
  • ✓Exclusion of gastrointestinal, renal, and metabolic causes of recurrent abdominal pain
  • ✓Family history of migraine (supports diagnosis)
  • ✓Stereotypical pattern to episodes (similar presentation each time)
  • ✓Intractability documentation: failed prophylactic therapy
  • ✓At least 2 episodes meeting diagnostic criteria

Commonly Confused Codes

  • •R10.9 (Unspecified abdominal pain): non-specific symptom; use abdominal migraine code when diagnosis is established
  • •K58.x (Irritable bowel syndrome): chronic GI disorder, not episodic with complete symptom-free intervals
  • •R11.15 (Cyclical vomiting syndrome, unrelated to migraine): vomiting-predominant without abdominal pain focus
  • •G43.A0-G43.A1 (Cyclical vomiting in migraine): vomiting-predominant migraine variant vs. pain-predominant abdominal migraine
  • •K59.8 (Other specified functional intestinal disorders): functional GI disorders lack the episodic migraine pattern

Child Codes

G43.D0Abdominal migraine, not intractable
G43.D1Abdominal migraine, intractable

Code Hierarchy

└G43Migraine└G43.DAbdominal migraine└G43.D1Abdominal migraine, intractable
└G43.D1Abdominal migraine, intractable

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