2027 ICD-10-CM Diagnosis Code P04.11Newborn affected by maternal antineoplastic chemotherapy

ICD-10-CM Codes›P00–P96›P00-P04›P04

ICD-10-CM P04.11
CMSSource: CMS FY 2027 ICD-10-CM dataset · Effective Oct 1, 2026 – Sep 30, 2027

P04.11 is a billable ICD-10-CM diagnosis code for newborn affected by maternal antineoplastic chemotherapy. It is valid on HIPAA claims for fiscal year 2027 (October 1, 2026 through September 30, 2027) and groups to MS-DRG 794. Coders also document this condition as neonatal disorder caused by antineoplastic agent transmitted via breast milk. In AHRQ's Clinical Classifications Software (CCSR), this diagnosis falls under Newborn affected by maternal conditions or complications of labor/delivery.

For Medicare Advantage risk adjustment, P04.11 maps to CMS-HCC Category 137 (Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications) under the V28 model, adding a risk factor of about 0.424 for a community, non-dual, aged beneficiary in payment year 2027.

Code Identity

ICD-10-CM Code
P04.11
Billable Status
Yes — Valid for Submission
Code Describes
Newborn affected by maternal antineoplastic chemotherapy
Short Description
Newborn affected by maternal antineoplastic chemotherapy
Same as the full description in the CMS dataset.
Parent Code
P04.1
Newborn affected by other maternal medication

Code Classification

ChapterP00–P96Certain conditions originating in the perinatal period
SectionP00-P04Newborn affected by maternal factors and by complications of pregnancy, labor, and delivery
CategoryP04Newborn affected by noxious substances transmitted via placenta or breast milk
This CodeP04.11Newborn affected by maternal antineoplastic chemotherapy

Medicare Risk Adjustment (HCC)Billing

P04.11 maps to a payment category in the CMS-HCC model used to risk-adjust Medicare Advantage payments. Weights are the published community factors for payment year 2027.

CMS-HCC V28 Category (Payment Model)
HCC 137— Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications
Payment HCC · PY 2027 one of 308 ICD-10-CM codes in this category
Risk Adjustment Factor (RAF) Weight
+0.424
community, non-dual, aged · ranges 0.297–0.502 across segments
Hierarchy
Superseded by HCC 135 and HCC 136
a more severe related category takes the payment when both are reported
Prior Model (CMS-HCC V24)
Not mapped under V24
this diagnosis newly risk-adjusts under the V28 model
Part D (RxHCC)
Not mapped
P04.11 does not risk-adjust in the RxHCC prescription drug model

Source: CMS Payment Year 2027 risk adjustment mappings and model software. Weights are relative factors, not dollar amounts; a beneficiary's total RAF also includes demographics and interactions. Browse all CMS-HCC categories.

Approximate SynonymsGuidance

Alternate terms and clinical phrases that map to this code.

  • Neonatal disorder caused by antineoplastic agent transmitted via breast milk

Instructional NotesGuidance

Instructions from the official ICD-10-CM Tabular List that apply to P04.11: its own notes plus those printed at P04.1, P04, block P00-P04, and Chapter 16. A note printed at a category, block or chapter applies to every code under it.

Includes

Further defines, or gives examples of, the content of the category.

From P04 Newborn affected by noxious substances transmitted via placenta or breast milk applies to 22 codes
  • nonteratogenic effects of substances transmitted via placenta
From Chapter 16 (P00-P96) Certain conditions originating in the perinatal period applies to 463 codes
  • conditions that have their origin in the fetal or perinatal period (before birth through the first 28 days after birth) even if morbidity occurs later

Excludes1

Not coded here: the excluded code is never reported together with this one, unless the two conditions are unrelated.

From P04.1 Newborn affected by other maternal medication applies to 10 codes
  • dysmorphism due to warfarin (Q86.2)
  • fetal hydantoin syndrome (Q86.1)

Excludes2

Not included here: the excluded condition is not part of this code, but a patient may have both, so both codes may be reported.

From P04.1 Newborn affected by other maternal medication applies to 10 codes
  • maternal anesthesia and analgesia in pregnancy, labor and delivery (P04.0)
  • maternal use of drugs of addiction (P04.4-)
From P04 Newborn affected by noxious substances transmitted via placenta or breast milk applies to 22 codes
  • 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.-)
From Chapter 16 (P00-P96) Certain conditions originating in the perinatal period applies to 463 codes
  • congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
  • endocrine, nutritional and metabolic diseases (E00-E88)
  • injury, poisoning and certain other consequences of external causes (S00-T88)
  • neoplasms (C00-D49)
  • tetanus neonatorum (A33)

Code First

The underlying condition named in the note is sequenced before this code.

From P04.1 Newborn affected by other maternal medication applies to 10 codes
  • if applicable, withdrawal symptoms from maternal use of drugs of addiction (P96.1)
  • withdrawal symptoms from therapeutic use of drugs in newborn (P96.2)
From P04 Newborn affected by noxious substances transmitted via placenta or breast milk applies to 22 codes
  • any current condition in newborn, if applicable

Notes

General instructions on how these codes are used.

From Block P00-P04 Newborn affected by maternal factors and by complications of pregnancy, labor, and delivery applies to 70 codes
  • These codes are for use when the listed maternal conditions are specified as the cause of confirmed morbidity or potential morbidity which have their origin in the perinatal period (before birth through the first 28 days after birth).
From Chapter 16 (P00-P96) Certain conditions originating in the perinatal period applies to 463 codes
  • Codes from this chapter are for use on newborn records only, never on maternal records

Source: CMS ICD-10-CM Tabular List. How to read instructional notes.

Referenced in Other NotesGuidance

Instructional notes printed at other codes that name P04.11, its category, or a range that includes it.

Excludes1 1

These codes carry an Excludes1 note naming P04.11: they are not reported together with it, unless the two conditions are unrelated.

  • P93 Reactions and intoxications due to drugs administered to newborn
    reactions and intoxications from maternal opiates, tranquilizers and other medication (P04.0-P04.1, P04.4-) names P04.0-P04.1, which includes this code

Excludes2 5

These codes carry an Excludes2 note naming P04.11: its condition is not part of those codes, and both may be reported when the patient has both.

  • P00 Newborn affected by maternal conditions that may be unrelated to present pregnancy
    newborn affected by noxious substances transmitted via placenta or breast milk (P04.-) names P04.-, which includes this code
  • P04.0 Newborn affected by maternal anesthesia and analgesia in pregnancy, labor and delivery
    newborn affected by other maternal medication (P04.1-) names P04.1-, which includes this code
  • P04.42 Newborn affected by maternal use of hallucinogens
    newborn affected by other maternal medication (P04.1-) names P04.1-, which includes this code
  • Q86 Congenital malformation syndromes due to known exogenous causes, not elsewhere classified
    nonteratogenic effects of substances transmitted via placenta or breast milk (P04.-) names P04.-, which includes this code
  • Z77 Other contact with and (suspected) exposures hazardous to health
    newborn affected by noxious substances transmitted via placenta or breast milk (P04.-) names P04.-, which includes this code

Index to Diseases and InjuriesGuidance

Alphabetical index entries that point to this code.

Clinical ClassificationClinical

AHRQ’s CCSR groups this code into broader clinical categories.

CCSR PNL010
Newborn affected by maternal conditions or complications of labor/delivery
Default principal diagnosis: inpatient Yes · outpatient Yes

Code History & ChangesHistory

Replacement P04.11 replaces the following previously assigned code(s):

  • P04.1 - Newborn affected by oth maternal medication
  • P04.1 - Newborn affected by other maternal medication
FY 2019AddedAdded to the ICD-10-CM code setEffective October 1, 2018.
FY 2020–2026No changes
FY 2027CurrentCurrent code set, no changesEffective October 1, 2026 through September 30, 2027.

Questions About P04.11Overview

What is the ICD-10 code for newborn affected by maternal antineoplastic chemotherapy?

The ICD-10-CM code for newborn affected by maternal antineoplastic chemotherapy is P04.11 (sometimes written as P0411). It is billable on HIPAA-covered claims from October 1, 2026 through September 30, 2027.

Is P04.11 (Newborn affected by other maternal medication) a billable code?

Yes. This is a billable ICD-10-CM code, specific enough to report newborn affected by maternal antineoplastic chemotherapy on HIPAA-covered claims from October 1, 2026 through September 30, 2027.

What MS-DRG does P04.11 group to?

When newborn affected by maternal antineoplastic chemotherapy is the principal diagnosis on an inpatient stay, it groups to MS-DRG 794 (neonate with Other Significant Problems), which carries a relative weight of 1.4934. Higher weights mean higher Medicare reimbursement.

Can P04.11 be reported with Q86.2?

Not as a rule. The Excludes1 note at P04.1, which applies to P04.11, lists "dysmorphism due to warfarin (Q86.2)". An Excludes1 note means the excluded code is never reported together with this one; the only exception is when the two conditions are unrelated to each other (Official Guidelines, Section I.A.12.a).

What is coded first with P04.11?

The Code First note at P04.1, which applies to P04.11, reads: if applicable, withdrawal symptoms from maternal use of drugs of addiction (P96.1); withdrawal symptoms from therapeutic use of drugs in newborn (P96.2). When one of these applies, it is sequenced before P04.11.

What HCC is P04.11?

P04.11 (newborn affected by maternal antineoplastic chemotherapy) maps to CMS-HCC Category 137 (Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications), commonly written as HCC 137, in the CMS-HCC V28 model used for Medicare Advantage risk adjustment in payment year 2027. It does not map to any RxHCC in the Part D prescription drug model.

Does P04.11 risk-adjust for Medicare Advantage payment?

Yes. When documented and reported on a Medicare Advantage encounter, P04.11 adds a risk adjustment factor of about 0.424 to the beneficiary's RAF score for a community, non-dual, aged enrollee (published V28 weights range from 0.297 to 0.502 depending on the payment segment). A more severe related category (HCC 135 and HCC 136) supersedes it when both are reported. See the full factor table on the HCC 137 category page.