P04.3

P04.3: Newborn affected by maternal use of alcohol

Billable / specific codeICD-10-CM

P04.3 is a billable, specific ICD-10-CM code for newborn affected by maternal use of alcohol. It is valid for submission on a claim.

Check P04.3 with the rest of the claim: free scrubber

Excludes1: never code together

These conditions cannot occur together. Billing both on the same encounter is a denial.

fetal alcohol syndrome (Q86.0)

Excludes2 inherited from the categories above P04.3

Not part of this code, but both may be coded when both are present.

Written on P04: Newborn affected by noxious substances transmitted via placenta or breast milk

congenital malformations (Q00-Q99)
encounter for observation of newborn for suspected diseases and conditions ruled out (Z05.-)
neonatal jaundice from excessive hemolysis due to drugs or toxins transmitted from mother (P58.4)
newborn in contact with and (suspected) exposures hazardous to health not transmitted via placenta or breast milk (Z77.-)

Risk adjustment

P04.3 risk-adjusts. Under the CMS-HCC V28 model it maps to this category:

HCC 137 Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications0.424 RAF

Coefficient shown for the Community Non-dual Aged segment. A higher HCC in the same hierarchy will suppress this one, so capturing it does not always add score. Look up the whole chart to see which of its HCCs the hierarchy would zero.

Medicare coverage

P04.3 is named in 1 Medicare coverage policy: 1 listing it as supporting medical necessity. Which one applies depends on your Medicare contractor.

A57189Billing and Coding: Serum Magnesium

Alphabetic index entries that lead here

Newborn›affected by›maternal›alcohol

Code history

Unchanged in every release from FY2024 to FY2027.