Question 1

What is ICD-10 code R04.1?

Accepted Answer

R04.1 is the ICD-10-CM diagnosis code for hemorrhage from throat. Bleeding from the throat or pharyngeal area, which may result from infection, trauma, or vascular abnormalities. R04.1 sits in the ICD-10-CM chapter for symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (r00-r99), within the section covering symptoms and signs involving the circulatory and respiratory systems (r00-r09).

R04.1 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 source of bleeding (pharynx, tonsils, larynx) if documented in the medical record.

Question 2

Is R04.1 an HCC code?

Accepted Answer

No. R04.1 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 R04.1 billable?

Accepted Answer

Yes. R04.1 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. R04.1 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 R04.1 map to under V28?

Accepted Answer

R04.1 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 R04.1 pay in RAF?

Accepted Answer

R04.1 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 R04.1?

Accepted Answer

R04.1 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 R04.1 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 R04.1?

Accepted Answer

Specify the source of bleeding (pharynx, tonsils, larynx) if documented in the medical record Investigate and code any underlying cause such as infection, malignancy, or bleeding disorder R04.1 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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R04.1

Is R04.1 an HCC code?

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Excludes 2, Not included here, may code separately

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R04.1 ICD-10-CM Code: Hemorrhage from throat

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R04.1

Is R04.1 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 R04.1 in HCC Buddy