Question 1

What is ICD-10 code P61.4?

Accepted Answer

P61.4 is the ICD-10-CM diagnosis code for other congenital anemias, not elsewhere classified. Low red blood cell count in a newborn from causes other than prematurity or fetal blood loss, such as hemolysis or bone marrow disorders. P61.4 sits in the ICD-10-CM chapter for certain conditions originating in the perinatal period (p00-p96), within the section covering hemorrhagic and hematological disorders of newborn (p50-p61).

P61.4 is a billable ICD-10-CM code but does not map to a payment HCC under the CMS-HCC V28, V24, ESRD, or RxHCC risk adjustment models. It can be reported on Medicare Advantage encounter data submissions but it does not contribute to a beneficiary's RAF score and therefore does not affect risk-adjusted payments to the plan.

Use this code only when the anemia is congenital but does not fit into P61.2 or P61.3 categories.

Question 2

Is P61.4 an HCC code?

Accepted Answer

No. P61.4 is a billable ICD-10-CM code but does not map to any payment HCC category under the CMS-HCC V28, V24, ESRD, or RxHCC risk adjustment models. It can still be reported on Medicare Advantage encounter data submissions, but it does not contribute to the beneficiary's Risk Adjustment Factor (RAF) score and therefore does not affect the risk-adjusted capitation payment to the plan. V28 reached 100% phase-in for payment year 2026.

Question 3

Is P61.4 billable?

Accepted Answer

Yes. P61.4 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. P61.4 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.

Question 4

Which HCC does P61.4 map to under V28?

Accepted Answer

P61.4 does not map to a CMS-HCC V28 payment category. Check the current CMS-HCC V28 model file for payment year 2026 rather than an older V24 tip sheet.

Question 5

What does P61.4 pay in RAF?

Accepted Answer

P61.4 has no separately stated V28 community RAF weight. If it is not a V28 payment HCC, it adds nothing to a community RAF score.

Question 6

What is the V28 vs V24 difference for P61.4?

Accepted Answer

P61.4 does not map to a payment HCC under either the CMS-HCC V28 risk adjustment model or the older V24 model. V28 reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition. Because neither community model rewards P61.4 with a risk adjustment factor, it contributes zero to a Medicare Advantage beneficiary's V28/V24 community RAF score in either version. Coders should check whether provider documentation supports a more specific child code that does map to a community payment HCC.

Question 7

What documentation supports P61.4?

Accepted Answer

Use this code only when the anemia is congenital but does not fit into P61.2 or P61.3 categories Document the specific etiology and any associated findings to justify the diagnosis P61.4 is not a CMS-HCC payment code, so MEAT is not the payment hook. Documentation still has to support the diagnosis if you report it.

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P61.4

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P61.4 ICD-10-CM Code: Other congenital anemias, not elsewhere classified

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P61.4

Is P61.4 an HCC code?

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