What is ICD-10 code P04.16?

P04.16 is the ICD-10-CM diagnosis code for Newborn affected by maternal use of amphetamines. A newborn experiencing health problems caused by the mother's use of amphetamines during pregnancy, which can result in growth problems, behavioral issues, or withdrawal symptoms. P04.16 is a billable code, meaning it can be reported on a claim as a primary or secondary diagnosis when supported by documentation. P04.16 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.

Yes. P04.16 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. P04.16 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.

Which HCC does P04.16 map to under V28?

P04.16 maps to CMS-HCC V28 137 (Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications). The category number and label come from the CMS-HCC V28 model file for payment year 2026.

What does P04.16 pay in RAF?

P04.16 carries a community, non-dual, aged (CNA) RAF weight of 0.424 under CMS-HCC V28 for payment year 2026. The weight comes from the CMS V28 relative-factor file, not a hand-typed table.

What is the V28 vs V24 difference for P04.16?

CMS phased in the V28 risk adjustment model over payment years 2024 (33%), 2025 (67%), and 2026 (100%), replacing V24. V28 consolidates HCC categories, removes some lower-acuity conditions, and recalibrates RAF weights across the entire model. P04.16 is a payment HCC under V28 (Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications) but was not retained as a payment HCC under V24. Both models can still appear in legacy data and in payer-specific lookback periods.

What documentation supports P04.16?

Document specific newborn manifestations such as irritability, poor feeding, or growth restriction to justify the diagnosis Distinguish between maternal amphetamine use history and actual documented effects on the newborn Because P04.16 maps to a payment HCC, the documentation must also satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's risk adjustment score. See the MEAT criteria checklist at /meat-criteria for what Monitor, Evaluate, Assess, or Treat looks like in a note. MEAT is generic documentation evidence, not a payer-specific rule.

2026 ICD-10-CM P04.16: Newborn affected

P04.16 maps to CMS-HCC V28 137 (RAF 0.424). Documentation must support MEAT. MEAT criteria · RAF calculator · free HCC coding tools

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Code lookupP04.16Effective periodFY2026 Apr Update (Apr 1-Sep 30)

FY 2026 Apr update / Certain conditions originating in the perinatal period (P00-P96) / Newborn affected by maternal factors and by complications of pregnancy, labor, and delivery (P00-P04)

P04.16

Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidance

Newborn affected by maternal use of amphetamines

A newborn experiencing health problems caused by the mother's use of amphetamines during pregnancy, which can result in growth problems, behavioral issues, or withdrawal symptoms.

Buddy Insight

CMS-HCC V28

Mapped

HCC 137

Drug Use Disorder, Moderate/S...

RAF 0.424

CMS-HCC V24

N/A

—

Not risk-adjusted for this model/period.

Not mapped

ACA/HHS

Mapped

HCC 82

HHS-HCC 82

Varies by metal level

ESRD/PACE

N/A

—

Not risk-adjusted for this model/period.

Not mapped

RXHCC

N/A

—

Not risk-adjusted for this model/period.

Not mapped

Code Book Path

Official

P04Newborn affected by noxious substances transmitted via placenta or breast milk

P04.1Newborn affected by other maternal medication

P04.16Newborn affected by maternal use of amphetamines

Inclusion Terms

Official

ICD-10-CM does not list inclusion terms for P04.16 in this effective period.

Excludes 2

Official

maternal anesthesia and analgesia in pregnancy, labor and delivery (P04.0)
maternal use of drugs of addiction (P04.4-)

Related Child Codes

Official

P04.11Newborn affected by maternal antineoplastic chemotherapy

P04.12Newborn affected by maternal cytotoxic drugs

P04.13Newborn affected by maternal use of anticonvulsants

P04.14Newborn affected by maternal use of opiates

P04.15Newborn affected by maternal use of antidepressants

Includes

Official

ICD-10-CM does not list Includes notes for P04.16 in this effective period.

Excludes 1

Official

dysmorphism due to warfarin (Q86.2)
fetal hydantoin syndrome (Q86.1)

Code First

Official

, if applicable, withdrawal symptoms from maternal use of drugs of addiction (P96.1)
withdrawal symptoms from therapeutic use of drugs in newborn (P96.2)

Use Additional

Official

ICD-10-CM does not list Use Additional Code instructions for P04.16 in this effective period.

Code Also

Official

ICD-10-CM does not list Code Also instructions for P04.16 in this effective period.

Buddy Documentation Tip

HCC Buddy guidance

Documentation of maternal amphetamine use during pregnancy

Type of amphetamine (prescription vs illicit methamphetamine)

Duration and pattern of maternal use

Growth parameters and gestational age assessment

MEAT Support

HCC Buddy guidance

Documentation of maternal amphetamine use during pregnancy

Type of amphetamine (prescription vs illicit methamphetamine)

Duration and pattern of maternal use

Growth parameters and gestational age assessment

Audit Caution

HCC Buddy guidance

Confusing amphetamines with cocaine or other stimulants

Using general drug addiction codes when amphetamine specific

Missing documentation of specific stimulant type

Incorrectly coding growth restriction as separate condition

Common Mistakes

HCC Buddy guidance

P04.41 — Newborn affected by maternal use of cocaine (cocaine vs amphetamine)

P04.40 — Newborn affected by maternal use of unspecified drugs of addiction

P05.9 — Slow fetal growth, unspecified (growth restriction without drug cause)

P96.1 — Neonatal withdrawal symptoms from maternal drug use

Current with CMS: FY2026 ICD-10-CM Apr 1 update (effective Apr 1 – Sep 30, 2026) · CMS-HCC V28, 100% phased in for payment year 2026. FY2027 code set already staged for October 1, 2026. How HCC Buddy stays current →

Is P04.16 an HCC code?

Yes. P04.16 (Newborn affected by maternal use of amphetamines) maps to Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications under the CMS-HCC V28 risk adjustment model, with a community non-dual aged RAF of 0.424. It is billable for payment year 2026.

Coder answer: P04.16 is billable and maps to V28 HCC 137, Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications. Open it in the Code Book for the tabular path, RAF, and MEAT checklist.

Code: P04.16
Description: Newborn affected by maternal use of amphetamines
HCC (V28): HCC 137 — Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications
RAF: 0.424
Billable: Yes
Payment year: 2026

HCC Category Mapping

V28HCC 137, Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications

0.424

Each model's RAF is its CMS base weight for that model's standard population, so weights are not directly comparable across models: CMS-HCC V28 and V24 use Community, Non-Dual, Aged; ESRD uses the dialysis continuing-enrollee model; RxHCC is the Part D continuing-enrollee, non-low-income, aged weight (a larger scale than CMS-HCC). ACA/HHS has no single weight — it varies by metal level. Actual per-patient RAF contribution depends on member segment, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains in use during the transition and for historical data.

Work P04.16 in the Code Book — tabular path, V28 RAF, and MEAT checklist →

MEAT Criteria for P04.16

For P04.16 to count as a valid HCC diagnosis in a given encounter, the provider's documentation must show MEAT: Monitor, Evaluate, Assess, or Treat. A diagnosis from a prior year does not carry forward automatically, it has to be re-documented and supported each calendar year.

MMonitor: signs, symptoms, disease progression, or lab trending documented in the note
EEvaluate: test results, medication response, or physical findings reviewed by the provider
AAssess: explicit mention in the assessment or plan with acknowledgment of status
TTreat: medication, referral, procedure, therapy, or counseling tied to the diagnosis

Only one of M/E/A/T is required to support the code, but the documentation must be specific enough to show that the provider actually addressed P04.16 during that encounter, not just copy-forwarded from a problem list.

Coder workflow notes

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What This Code Means

P04.16 is the ICD-10-CM diagnosis code for newborn affected by maternal use of amphetamines. A newborn experiencing health problems caused by the mother's use of amphetamines during pregnancy, which can result in growth problems, behavioral issues, or withdrawal symptoms. P04.16 sits in the ICD-10-CM chapter for certain conditions originating in the perinatal period (p00-p96), within the section covering newborn affected by maternal factors and by complications of pregnancy, labor, and delivery (p00-p04).

Under the CMS-HCC V28 risk adjustment model, P04.16 maps to Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications (HCC 137) with a community, non-dual, aged base RAF weight of 0.424. P04.16 was not retained as a payment HCC under the older V24 model, so V28 introduced or recategorized it during the 2024–2026 phase-in. V28 is the CMS-HCC risk adjustment model that reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition.

Document specific newborn manifestations such as irritability, poor feeding, or growth restriction to justify the diagnosis. Because P04.16 maps to a payment HCC, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's Medicare Advantage risk adjustment score. When documentation is ambiguous, coders should issue a provider query rather than assume the highest-specificity variant.

HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for P04.16 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.

Coding Tips

•Document specific newborn manifestations such as irritability, poor feeding, or growth restriction to justify the diagnosis
•Distinguish between maternal amphetamine use history and actual documented effects on the newborn

Clinical Significance

Maternal amphetamine use during pregnancy causes significant risk for intrauterine growth restriction, premature delivery, and neonatal complications including withdrawal symptoms and behavioral abnormalities. These newborns require comprehensive assessment and may need extended monitoring for developmental issues.