Question 1

What is ICD-10 code O92.13?

Accepted Answer

O92.13 is the ICD-10-CM diagnosis code for cracked nipple associated with lactation. Painful cracking or splitting of the nipple that occurs during breastfeeding and milk production. O92.13 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).

O92.13 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.

Distinguish between O92.12 (puerperium-related) and O92.13 (lactation-related) based on the clinical context and timing.

Question 2

Is O92.13 an HCC code?

Accepted Answer

No. O92.13 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 O92.13 billable?

Accepted Answer

Yes. O92.13 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. O92.13 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 O92.13?

Accepted Answer

O92.13 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 O92.13 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 O92.13?

Accepted Answer

Distinguish between O92.12 (puerperium-related) and O92.13 (lactation-related) based on the clinical context and timing Document any associated lactation complications or breastfeeding difficulties

HCC Buddy Code Card

O92.13

Is O92.13 an HCC code?

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Open O92.13 in the Interactive Encoder

O92.13 ICD-10-CM Code: Cracked nipple associated with lactation

HCC Buddy Code Card

O92.13

Is O92.13 an HCC code?

What This Code Means

Coding Tips

Child Codes

Code Hierarchy

Open O92.13 in the Interactive Encoder