Question 1

What is ICD-10 code O94?

Accepted Answer

O94 is the ICD-10-CM diagnosis code for sequelae of complication of pregnancy, childbirth, and the puerperium. Long-term health problems that result from complications that occurred during pregnancy, childbirth, or the recovery period after delivery. O94 sits in the ICD-10-CM chapter for pregnancy, childbirth and the puerperium (o00-o9a), within the section covering other obstetric conditions, not elsewhere classified (o94-o9a).

O94 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.

Use this code for late effects of pregnancy-related complications; the complication itself may have resolved but ongoing consequences remain.

Question 2

Is O94 an HCC code?

Accepted Answer

No. O94 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 O94 billable?

Accepted Answer

Yes. O94 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. O94 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 O94?

Accepted Answer

O94 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 O94 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 O94?

Accepted Answer

Use this code for late effects of pregnancy-related complications; the complication itself may have resolved but ongoing consequences remain Always code the specific sequela condition first, then use O94 as a secondary code to indicate it resulted from a pregnancy complication

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O94

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O94 ICD-10-CM Code: Sequelae of complication of pregnancy, childbirth, and the puerperium

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O94

Is O94 an HCC code?

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What This Code Means

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Work O94 in HCC Buddy