P04.81 ICD-10-CM Code: Newborn affected by maternal use of cannabis
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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)
P04.81
Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidanceNewborn affected by maternal use of cannabis
A newborn whose mother used cannabis (marijuana) during pregnancy, which may affect the baby's development and behavior.
Buddy Insight
Maternal cannabis use during pregnancy can affect fetal brain development and may cause subtle neurobehavioral effects in newborns including altered sleep patterns and behavioral regulation.
CMS-HCC V28
MappedHCC 137
RAF 0.424
CMS-HCC V24
N/A—
Not mapped
ACA/HHS
MappedHCC 82
Varies by metal level
ESRD/PACE
N/A—
Not mapped
RXHCC
N/A—
Not mapped
Code Book Path
Inclusion Terms
OfficialICD-10-CM does not list inclusion terms for P04.81 in this effective period.
Excludes 2
OfficialICD-10-CM does not list Excludes 2 notes for P04.81 in this effective period.
Related Child Codes
Includes
OfficialICD-10-CM does not list Includes notes for P04.81 in this effective period.
Excludes 1
OfficialICD-10-CM does not list Excludes 1 notes for P04.81 in this effective period.
Code First
OfficialICD-10-CM does not list Code First sequencing instructions for P04.81 in this effective period.
Use Additional
OfficialICD-10-CM does not list Use Additional Code instructions for P04.81 in this effective period.
Code Also
OfficialICD-10-CM does not list Code Also instructions for P04.81 in this effective period.
Buddy Documentation Tip
MEAT Support
Audit Caution
Common Mistakes
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 P04.81 an HCC code?
Yes. P04.81 (Newborn affected by maternal use of cannabis) 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: P04.81 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
- P04.81
- Description
- Newborn affected by maternal use of cannabis
- 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
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 P04.81 in the Code Book — tabular path, V28 RAF, and MEAT checklist →
MEAT Criteria for P04.81
For P04.81 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 P04.81 during that encounter, not just copy-forwarded from a problem list.
Coder workflow notes
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What This Code Means
P04.81 is the ICD-10-CM diagnosis code for newborn affected by maternal use of cannabis. A newborn whose mother used cannabis (marijuana) during pregnancy, which may affect the baby's development and behavior. P04.81 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, P04.81 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. P04.81 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.
Specify the trimester of exposure if documented, as timing affects fetal impact. Because P04.81 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 P04.81 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Specify the trimester of exposure if documented, as timing affects fetal impact
- •Document any neonatal manifestations such as poor feeding, irritability, or developmental delays with additional codes
Clinical Significance
Maternal cannabis use during pregnancy can affect fetal brain development and may cause subtle neurobehavioral effects in newborns including altered sleep patterns and behavioral regulation. These infants require monitoring for potential cognitive and behavioral development issues.
Documentation Requirements
- ✓Documentation of maternal cannabis use during pregnancy
- ✓Frequency and method of cannabis use
- ✓Timing of use relative to pregnancy stages
- ✓Clinical observations of newborn behavior
- ✓Sleep patterns and behavioral regulation assessment
- ✓Neurological examination findings
- ✓Developmental monitoring plans established