What is ICD-10 code P04.19?

P04.19 is the ICD-10-CM diagnosis code for Newborn affected by maternal use of unspecified medication. A newborn affected by the mother's use of medications during pregnancy when the specific type of medication is unknown or not specified. P04.19 is a billable code, meaning it can be reported on a claim as a primary or secondary diagnosis when supported by documentation. P04.19 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. P04.19 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. P04.19 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 P04.19 map to under V28?

P04.19 maps to CMS-HCC V28 HCC 137 (Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications). The category numbers, labels, and conditions come from the CMS-HCC V28 model file for payment year 2026.

What documentation supports P04.19?

This is a default code used when maternal medication exposure is documented but the specific drug class cannot be determined Attempt to obtain more specific medication information to allow for a more precise code assignment Because P04.19 maps to an HCC category, the documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) before the diagnosis is used for risk adjustment. 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 P04.19: Newborn affected

P04.19 maps to CMS-HCC V28 137. A source-labeled RAF reference is available. Documentation must support MEAT. MEAT criteria · RAF Calculator · free HCC coding tools

ICD-10-CM Code View

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Code lookupP04.19Effective 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)

P04.19

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

Newborn affected by maternal use of unspecified medication

A newborn affected by the mother's use of medications during pregnancy when the specific type of medication is unknown or not specified.

Buddy Insight

Newborn effects from unspecified maternal medication use indicates potential medication-related complications where the specific agent is unknown or undocumented.

CMS-HCC V28

Mapped

HCC 137

Drug Use Disorder, Moderate/S...

Code-level coefficient reference

CMS-HCC V24

Historical

Not used for standard CY2026 Medicare Advantage payment. Select a historical period to review V24.

Not used for CY2026 payment

ACA/HHS

N/A

—

Not risk-adjusted for this model/period.

Not mapped

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

P04.19Newborn affected by maternal use of unspecified medication

Inclusion Terms

Official

ICD-10-CM does not list inclusion terms for P04.19 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 P04.19 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 P04.19 in this effective period.

Code Also

Official

ICD-10-CM does not list Code Also instructions for P04.19 in this effective period.

Buddy Documentation Tip

HCC Buddy guidance

Documentation that newborn is affected by maternal medication

Clinical signs or symptoms suggesting medication effects

History of maternal medication use during pregnancy

Attempts to identify specific medications if possible

MEAT Support

HCC Buddy guidance

Documentation that newborn is affected by maternal medication

Clinical signs or symptoms suggesting medication effects

History of maternal medication use during pregnancy

Attempts to identify specific medications if possible

Audit Caution

HCC Buddy guidance

Using when specific medication is documented

Confusing with other noxious substance exposures

Missing attempts to identify specific medication

Using when no medication effects are documented

Common Mistakes

HCC Buddy guidance

P04.18 — Newborn affected by other maternal medication (specified vs unspecified)

P96.89 — Other specified conditions originating in the perinatal period

P04.89 — Newborn affected by other maternal noxious substances

P04.9 — Newborn affected by maternal noxious substance, unspecified

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 P04.19 an HCC code?

Yes. P04.19 (Newborn affected by maternal use of unspecified medication) maps to HCC 137, Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications under the CMS-HCC V28 risk adjustment model, with a source-labeled community non-dual aged reference coefficient of 0.424. Source-labeled code-level coefficients are references, not member totals. Actual contribution depends on complete member context, hierarchy and cleanup rules, interactions, and model year. HCC Buddy's RAF Calculator supports CMS-HCC V28 PY2026 and shows no score unless every required source and calculation check passes. It is billable for payment year 2026.

Coder answer: P04.19 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: P04.19
Description: Newborn affected by maternal use of unspecified medication
HCC (V28): HCC 137 — Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications
RAF reference coefficient: 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

These are source-labeled model coefficients, not member totals. A category may still be removed by hierarchy or model cleanup rules. 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 context, hierarchy and cleanup rules, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains available for historical review.

Work P04.19 in the Code Book — tabular path, V28 RAF reference, and MEAT checklist →

MEAT Criteria for P04.19

For P04.19 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 P04.19 during that encounter, not just copy-forwarded from a problem list.

Coder workflow notes

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What This Code Means

P04.19 is the ICD-10-CM diagnosis code for newborn affected by maternal use of unspecified medication. A newborn affected by the mother's use of medications during pregnancy when the specific type of medication is unknown or not specified. P04.19 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, P04.19 maps to Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications (HCC 137) with a source-labeled community, non-dual, aged reference coefficient of 0.424. No V24 mapping is shown for P04.19; use the applicable model and payment year when reviewing the V28 mapping. 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. Source-labeled code-level coefficients are references, not member totals. Actual contribution depends on complete member context, hierarchy and cleanup rules, interactions, and model year. HCC Buddy's RAF Calculator supports CMS-HCC V28 PY2026 and shows no score unless every required source and calculation check passes.

This is a default code used when maternal medication exposure is documented but the specific drug class cannot be determined. Because P04.19 maps to an HCC category, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) before the diagnosis is used for risk adjustment. 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, source-labeled coefficient references, and MEAT documentation criteria for P04.19 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.

Coding Tips

•This is a default code used when maternal medication exposure is documented but the specific drug class cannot be determined
•Attempt to obtain more specific medication information to allow for a more precise code assignment

Clinical Significance

Newborn effects from unspecified maternal medication use indicates potential medication-related complications where the specific agent is unknown or undocumented. These cases require systematic evaluation to identify possible medication effects and appropriate monitoring protocols.

Documentation Requirements

✓Documentation that newborn is affected by maternal medication
✓Clinical signs or symptoms suggesting medication effects
✓History of maternal medication use during pregnancy
✓Attempts to identify specific medications if possible
✓Clinical manifestations observed in the newborn
✓Monitoring protocols established
✓Response to supportive care measures

Commonly Confused Codes

•P04.18: Newborn affected by other maternal medication (specified vs unspecified)
•P96.89: Other specified conditions originating in the perinatal period
•P04.89: Newborn affected by other maternal noxious substances
•P04.9: Newborn affected by maternal noxious substance, unspecified