P28.5 ICD-10-CM Code: Respiratory failure of newborn
P28.5 maps to CMS-HCC V28 213. A source-labeled RAF reference is available. Confirm the documented diagnosis and applicable coding requirements. MEAT criteria · RAF Calculator · HCC Buddy coding tools
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FY 2026 Apr update / Certain conditions originating in the perinatal period (P00-P96) / Respiratory and cardiovascular disorders specific to the perinatal period (P19-P29)
P28.5
Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidanceRespiratory failure of newborn
A newborn's lungs are unable to provide adequate oxygen to the blood or remove carbon dioxide effectively, requiring respiratory support.
Buddy Insight
Respiratory failure of newborn represents the inability of the respiratory system to maintain adequate gas exchange, requiring immediate and intensive intervention.
CMS-HCC V28
MappedHCC 213
Coefficient HCC 213: 0.370 (Community Non-Dual Aged (CNA))
CMS-HCC V24
HistoricalHistorical
Not used for CY2026 payment
ACA/HHS
MappedHCC 127
Code-level coefficient reference
ESRD/PACE
N/A—
Not mapped
RXHCC
N/A—
Not mapped
Code Book Path
Inclusion Terms
OfficialNo inclusion terms are included in this display for P28.5. Check the code and parent instructions in the Code Book.
Excludes 2
Official- respiratory arrest of newborn (P28.81)
- respiratory distress of newborn (P22.0)
- congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)Inherited from P00-P96
- endocrine, nutritional and metabolic diseases (E00-E88)Inherited from P00-P96
- injury, poisoning and certain other consequences of external causes (S00-T88)Inherited from P00-P96
- neoplasms (C00-D49)Inherited from P00-P96
- tetanus neonatorum (A33)Inherited from P00-P96
Related Codes
Includes
Official- conditions that have their origin in the fetal or perinatal period (before birth through the first 28 days after birth) even if morbidity occurs laterInherited from P00-P96
Excludes 1
OfficialNo Excludes 1 notes are included in this display for P28.5. Check the code and parent instructions in the Code Book.
Code First
OfficialNo Code First sequencing instructions are included in this display for P28.5. Check the code and parent instructions in the Code Book.
Use Additional
OfficialNo Use Additional Code instructions are included in this display for P28.5. Check the code and parent instructions in the Code Book.
Code Also
Official- , if applicable, congenital malformations of the respiratory system (Q30-Q34)Inherited from P28
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 P28.5 an HCC code?
Yes. P28.5 (Respiratory failure of newborn) maps to HCC 213, Cardio-Respiratory Failure and Shock under the CMS-HCC V28 risk adjustment model, with a source-labeled community non-dual aged reference coefficient of 0.370. 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: P28.5 is billable and maps to V28 HCC 213, Cardio-Respiratory Failure and Shock. Open it in the Code Book for the tabular path, RAF, and MEAT checklist.
- Code
- P28.5
- Description
- Respiratory failure of newborn
- HCC (V28)
- HCC 213 — Cardio-Respiratory Failure and Shock
- RAF reference coefficient
- 0.370
- Billable
- Yes
- Payment year
- 2026
HCC Category Mapping
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 P28.5 in the Code Book — tabular path, V28 RAF reference, and MEAT checklist →
MEAT review for P28.5
For P28.5, confirm that the documentation supports the diagnosis and meets the applicable coding, encounter, program and payer requirements. MEAT (Monitor, Evaluate, Assess, or Treat) is a review mnemonic, not a universal CMS coding rule.
- 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
Coder workflow notes
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What This Code Means
P28.5 is the ICD-10-CM diagnosis code for respiratory failure of newborn. A newborn's lungs are unable to provide adequate oxygen to the blood or remove carbon dioxide effectively, requiring respiratory support. P28.5 sits in the ICD-10-CM chapter for certain conditions originating in the perinatal period (p00-p96), within the section covering respiratory and cardiovascular disorders specific to the perinatal period (p19-p29).
Under the CMS-HCC V28 risk adjustment model, P28.5 maps to Cardio-Respiratory Failure and Shock (HCC 213) with a source-labeled community, non-dual, aged reference coefficient of 0.370. For CY2026 non-PACE Medicare Advantage, CMS uses 100% of the 2024 CMS-HCC model (V28). PACE uses a separate model blend. 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.
Document the severity and underlying cause (prematurity, infection, aspiration, etc.). For P28.5, confirm that the documentation supports the diagnosis and meets the applicable coding, encounter, program and payer requirements. MEAT (Monitor, Evaluate, Assess, or Treat) is a review mnemonic, not a universal CMS coding rule. 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 P28.5 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Document the severity and underlying cause (prematurity, infection, aspiration, etc.)
- •Specify if mechanical ventilation or other respiratory support is required
Clinical Significance
Respiratory failure of newborn represents the inability of the respiratory system to maintain adequate gas exchange, requiring immediate and intensive intervention. This life-threatening condition often necessitates mechanical ventilation and carries significant risk for long-term complications including neurodevelopmental impairment and chronic lung disease.
Documentation Requirements
- ✓Clinical evidence of inadequate gas exchange
- ✓Blood gas analysis showing hypoxemia or hypercapnia
- ✓Gestational age and birth weight
- ✓Mechanical ventilation requirements
- ✓Oxygen saturation measurements
- ✓Associated respiratory distress signs
- ✓Underlying cause if identified
- ✓Response to respiratory interventions