Question 1

What is ICD-10 code O43.191?

Accepted Answer

O43.191 is the ICD-10-CM diagnosis code for other malformation of placenta, first trimester. The placenta has an abnormal structure or formation other than velamentous insertion or accreta, identified during the first trimester of pregnancy. O43.191 sits in the ICD-10-CM chapter for pregnancy, childbirth and the puerperium (o00-o9a), within the section covering maternal care related to the fetus and amniotic cavity and possible delivery problems (o30-o48).

O43.191 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 is a catch-all code for placental malformations not elsewhere classified; document the specific type of malformation.

Question 2

Is O43.191 an HCC code?

Accepted Answer

No. O43.191 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 O43.191 billable?

Accepted Answer

Yes. O43.191 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. O43.191 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 O43.191?

Accepted Answer

O43.191 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 O43.191 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 O43.191?

Accepted Answer

This is a catch-all code for placental malformations not elsewhere classified; document the specific type of malformation Verify trimester is first trimester (weeks 1-13) before assigning this code

O43.191

Is O43.191 an HCC code?

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Open O43.191 in the Interactive Encoder