Question 1

What is ICD-10 code N04.1?

Accepted Answer

N04.1 is the ICD-10-CM diagnosis code for nephrotic syndrome with focal and segmental glomerular lesions. A kidney disorder where the kidneys leak protein into the urine due to damage in specific areas of the kidney's filtering units, causing swelling and fluid retention in the body. N04.1 sits in the ICD-10-CM chapter for diseases of the genitourinary system (n00-n99), within the section covering glomerular diseases (n00-n08).

N04.1 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.

This code specifies focal and segmental involvement, meaning only some portions of the glomeruli are affected; document the extent of involvement in the medical record.

Question 2

Is N04.1 an HCC code?

Accepted Answer

No. N04.1 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 N04.1 billable?

Accepted Answer

Yes. N04.1 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. N04.1 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 N04.1?

Accepted Answer

N04.1 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 N04.1 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 N04.1?

Accepted Answer

This code specifies focal and segmental involvement, meaning only some portions of the glomeruli are affected; document the extent of involvement in the medical record Ensure documentation distinguishes this from diffuse glomerular lesions, which would use different N04 codes

N04.1

Is N04.1 an HCC code?

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Open N04.1 in the Interactive Encoder