Question 1

What is ICD-10 code P96.5?

Accepted Answer

P96.5 is the ICD-10-CM diagnosis code for complication to newborn due to (fetal) intrauterine procedure. A newborn experiences complications from a medical procedure performed on the fetus or in the womb during pregnancy, such as fetal surgery or amniocentesis. P96.5 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).

P96.5 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.

Specify the type of intrauterine procedure performed and the nature of the complication in supporting documentation.

Question 2

Is P96.5 an HCC code?

Accepted Answer

No. P96.5 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 P96.5 billable?

Accepted Answer

Yes. P96.5 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. P96.5 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

What is the V28 vs V24 difference for P96.5?

Accepted Answer

P96.5 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 model rewards P96.5 with a risk adjustment factor, it contributes zero to a Medicare Advantage beneficiary's RAF score in either version. Coders should check whether provider documentation supports a more specific child code that does map to a payment HCC.

Question 5

What should coders know when reporting P96.5?

Accepted Answer

Specify the type of intrauterine procedure performed and the nature of the complication in supporting documentation Use additional codes to describe the specific complication (infection, injury, etc.)

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P96.5

Is P96.5 an HCC code?

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P96.5 ICD-10-CM Code: Complication to newborn due to (fetal) intrauterine procedure

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P96.5

Is P96.5 an HCC code?

Get the V28 RAF + MEAT cheat sheet

What This Code Means

Coding Tips

Excludes 2, Not included here, may code separately

Child Codes

Code Hierarchy

Work P96.5 in HCC Buddy