Question 1

What is ICD-10 code O85?

Accepted Answer

O85 is the ICD-10-CM diagnosis code for puerperal sepsis. A serious bacterial infection of the uterus and surrounding tissues occurring after childbirth, characterized by fever and systemic illness. O85 sits in the ICD-10-CM chapter for pregnancy, childbirth and the puerperium (o00-o9a), within the section covering complications predominantly related to the puerperium (o85-o92).

O85 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 serious postpartum complication requiring antibiotic treatment; document the causative organism if identified.

Question 2

Is O85 an HCC code?

Accepted Answer

No. O85 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 O85 billable?

Accepted Answer

Yes. O85 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. O85 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 O85?

Accepted Answer

O85 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 O85 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 O85?

Accepted Answer

This is a serious postpartum complication requiring antibiotic treatment; document the causative organism if identified Link to appropriate sepsis codes (R65.2x) if systemic inflammatory response is documented

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O85

Is O85 an HCC code?

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O85 ICD-10-CM Code: Puerperal sepsis

HCC Buddy Code Card

O85

Is O85 an HCC code?

Get the V28 RAF + MEAT cheat sheet

What This Code Means

Coding Tips

Excludes 1, Do NOT code together

Excludes 2, Not included here, may code separately

Use Additional Code

Code Hierarchy

Work O85 in HCC Buddy