Question 1

What is ICD-10 code O43.811?

Accepted Answer

O43.811 is the ICD-10-CM diagnosis code for Placental infarction, first trimester. An area of the placenta has died or become necrotic (infarction) during the first trimester of pregnancy, which can affect oxygen and nutrient transfer to the fetus. O43.811 is a billable code, meaning it can be reported on a claim as a primary or secondary diagnosis when supported by documentation. O43.811 is part of the FY2026 ICD-10-CM code set published by the CMS National Center for Health Statistics and used on Medicare, Medicaid, and commercial claims in the United States.

Question 2

Is O43.811 an HCC code?

Accepted Answer

No. O43.811 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 O43.811 billable?

Accepted Answer

Yes. O43.811 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. O43.811 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

Which HCC does O43.811 map to under V28?

Accepted Answer

O43.811 does not map to a CMS-HCC V28 payment category. Check the current CMS-HCC V28 model file for payment year 2026 rather than an older V24 tip sheet.

Question 5

What does O43.811 pay in RAF?

Accepted Answer

O43.811 has no separately stated V28 community RAF weight. If it is not a V28 payment HCC, it adds nothing to a community RAF score.

Question 6

What is the V28 vs V24 difference for O43.811?

Accepted Answer

O43.811 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 O43.811 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 7

What documentation supports O43.811?

Accepted Answer

Placental infarction is typically identified on pathology after delivery; ensure documentation specifies when it was diagnosed Document the extent and clinical significance of the infarction if known, as this may affect fetal monitoring and delivery planning O43.811 is not a CMS-HCC payment code, so MEAT is not the payment hook. Documentation still has to support the diagnosis if you report it.

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O43.811

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O43.811 ICD-10-CM Code: Placental infarction, first trimester

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O43.811

Is O43.811 an HCC code?

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