P96.1
BillableNeonatal withdrawal symptoms from maternal use of drugs of addiction
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is P96.1 an HCC code?
Yes. P96.1 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 P96.1
For P96.1to 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 P96.1 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
P96.1 is the ICD-10-CM diagnosis code for neonatal withdrawal symptoms from maternal use of drugs of addiction. A newborn experiences withdrawal symptoms such as tremors, irritability, or feeding difficulties because the mother used addictive drugs during pregnancy. P96.1 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, P96.1 maps to Drug Use Disorder/Substance Use Disorder, Moderate/Severe (HCC 137) with a community, non-dual, aged base RAF weight of 0.358. P96.1 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.
Always code the maternal drug use separately using codes from category O9A.3 to document the substance involved. Because P96.1 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 P96.1 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Always code the maternal drug use separately using codes from category O9A.3 to document the substance involved
- •Document specific withdrawal symptoms observed (tremors, seizures, poor feeding) for complete clinical picture
Clinical Significance
Neonatal withdrawal from maternal drug addiction represents serious complications requiring intensive monitoring and treatment. This diagnosis indicates in-utero drug exposure with resulting withdrawal symptoms that can affect feeding, neurological development, and require specialized neonatal abstinence syndrome protocols.
Documentation Requirements
- ✓Clear documentation of maternal drug use during pregnancy
- ✓Specific drugs of addiction identified (opioids, cocaine, amphetamines, etc.)
- ✓Clinical signs of neonatal withdrawal syndrome
- ✓Neonatal Abstinence Syndrome (NAS) scoring if used
- ✓Timeline of symptom onset after birth
- ✓Response to withdrawal treatment protocols
- ✓Feeding difficulties and growth parameters
- ✓Social services involvement and discharge planning
Excludes 1 — Do NOT code together
- reactions and intoxications from maternal opiates and tranquilizers administered during labor and delivery (P04.0)