P04.3
BillableNewborn affected by maternal use of alcohol
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is P04.3 an HCC code?
Yes. P04.3 maps to Drug Use Disorder/Substance Use Disorder, Moderate/Severe under the CMS-HCC V28 risk adjustment model.
HCC Category Mapping
RAF weights shown are the community, non-dual, aged base weights from the CMS risk adjustment model file. 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.
MEAT Criteria for P04.3
For P04.3to 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 P04.3 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
P04.3 is the ICD-10-CM diagnosis code for newborn affected by maternal use of alcohol. A newborn experiencing health problems caused by the mother's alcohol consumption during pregnancy, which may include fetal alcohol spectrum disorders or other developmental issues. P04.3 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, P04.3 maps to Drug Use Disorder/Substance Use Disorder, Moderate/Severe (HCC 137) with a community, non-dual, aged base RAF weight of 0.358. P04.3 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 the timing and amount of maternal alcohol exposure and specific newborn manifestations. Because P04.3 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 P04.3 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Document the timing and amount of maternal alcohol exposure and specific newborn manifestations
- •If fetal alcohol syndrome is diagnosed, consider using the more specific code F78.0 in addition to this code
Clinical Significance
Maternal alcohol use during pregnancy can cause fetal alcohol spectrum disorders with lifelong cognitive, behavioral, and physical complications. These newborns require comprehensive evaluation for characteristic features and long-term developmental monitoring and intervention services.
Documentation Requirements
- ✓Documentation of maternal alcohol use during pregnancy
- ✓Amount and pattern of alcohol consumption if known
- ✓Clinical features consistent with fetal alcohol exposure
- ✓Growth parameters and facial feature assessment
- ✓Neurological and developmental evaluations
- ✓Cardiac and other organ system screenings
- ✓Long-term developmental monitoring plans
Excludes 1 — Do NOT code together
- fetal alcohol syndrome (Q86.0)