P91.819
BillableNeonatal encephalopathy, unspecified
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is P91.819 an HCC code?
Yes. P91.819 maps to Coma, Brain Compression/Anoxic Damage 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 P91.819
For P91.819 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 P91.819 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
P91.819 is the ICD-10-CM diagnosis code for neonatal encephalopathy, unspecified. A newborn's brain inflammation or dysfunction where the specific cause or type is not identified or documented. P91.819 sits in the ICD-10-CM chapter for certain conditions originating in the perinatal period (p00-p96), within the section covering other disorders originating in the perinatal period (p90-p96).
Under the CMS-HCC V28 risk adjustment model, P91.819 maps to Coma, Brain Compression/Anoxic Damage (HCC 202) with a community, non-dual, aged base RAF weight of 0.000. P91.819 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.
Use this code only when the cause of neonatal encephalopathy cannot be determined or is not documented. Because P91.819 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 P91.819 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Use this code only when the cause of neonatal encephalopathy cannot be determined or is not documented
- •Query the provider if additional clinical information is available to assign a more specific encephalopathy code
Clinical Significance
Neonatal encephalopathy unspecified indicates brain dysfunction in a newborn where the specific cause has not been identified. This diagnosis represents significant neurological concern requiring comprehensive evaluation and ongoing monitoring for developmental outcomes.
Documentation Requirements
- ✓Documentation of neonatal encephalopathy without identified cause
- ✓Clinical signs of brain dysfunction present
- ✓Comprehensive diagnostic workup performed but inconclusive
- ✓Neurological examination abnormalities documented
- ✓Exclusion of specific causes like HIE or infection
- ✓Response to supportive care measures
- ✓Ongoing investigation for underlying etiology
- ✓Neurodevelopmental follow-up plans established