Question 1

What is ICD-10 code O91.011?

Accepted Answer

O91.011 is the ICD-10-CM diagnosis code for infection of nipple associated with pregnancy, first trimester. An infection of the nipple that develops during the first three months of pregnancy. O91.011 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).

O91.011 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.

Confirm the trimester is documented in the medical record before assigning this code.

Question 2

Is O91.011 an HCC code?

Accepted Answer

No. O91.011 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 O91.011 billable?

Accepted Answer

Yes. O91.011 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. O91.011 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 O91.011 map to under V28?

Accepted Answer

O91.011 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 O91.011 pay in RAF?

Accepted Answer

O91.011 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 O91.011?

Accepted Answer

O91.011 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 O91.011 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 O91.011?

Accepted Answer

Confirm the trimester is documented in the medical record before assigning this code Differentiate between nipple infection during pregnancy versus during lactation or postpartum period O91.011 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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O91.011

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O91.011 ICD-10-CM Code: Infection of nipple associated with pregnancy, first trimester

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O91.011

Is O91.011 an HCC code?

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