2026 ICD-10-CM Diagnosis Code P04.3Newborn affected by maternal use of alcohol
P04.3 is a billable ICD-10-CM diagnosis code for newborn affected by maternal use of alcohol. It is valid on HIPAA claims for fiscal year 2026 (October 1, 2025 through September 30, 2026) and groups to MS-DRG 794. Coders also document this condition as neonatal disorder caused by maternal alcohol transmitted via breast milk. In AHRQ's Clinical Classifications Software (CCSR), this diagnosis falls under Fetal alcohol syndrome and Newborn affected by maternal conditions or complications of labor/delivery.
For Medicare Advantage risk adjustment, P04.3 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 2026.
Code Identity
Code Classification
Medicare Risk Adjustment (HCC)Billing
P04.3 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 2026.
Source: CMS Payment Year 2026 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 maternal alcohol transmitted via breast milk
- Neurodevelopmental disorder due to maternal use of alcohol
Tabular List NotesGuidance
Coding notes and annotation back-references applicable to this code.
Type 1 Excludes
- fetal alcohol syndrome Q86.0
A type 1 excludes note is a pure excludes note. It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
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.
Patient EducationClinical
Fetal Alcohol Spectrum Disorders
Alcohol can harm your baby at any stage during a pregnancy. That includes the earliest stages, before you even know you are pregnant. Drinking during pregnancy can cause a group of conditions called fetal alcohol spectrum disorders (FASDs).
Read the full article at MedlinePlus
Courtesy of MedlinePlus, a service of the U.S. National Library of Medicine.
Convert P04.3 to ICD-9-CMHistory
The closest ICD-9-CM equivalents under the General Equivalence Mappings.
Code HistoryHistory
Questions About P04.3Overview
What is the ICD-10 code for newborn affected by maternal use of alcohol?
The ICD-10-CM code for newborn affected by maternal use of alcohol is P04.3 (sometimes written as P043). It is billable on HIPAA-covered claims from October 1, 2025 through September 30, 2026.
Is P04.3 a billable code?
Yes. This is a billable ICD-10-CM code, specific enough to report newborn affected by maternal use of alcohol on HIPAA-covered claims from October 1, 2025 through September 30, 2026.
What MS-DRG does P04.3 group to?
When newborn affected by maternal use of alcohol 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 1.4759. Higher weights mean higher Medicare reimbursement.
What is the ICD-9 equivalent of P04.3?
Under the General Equivalence Mappings, newborn affected by maternal use of alcohol converts to ICD-9-CM 760.71 (maternl alc aff NB/fetus). The mapping is approximate, so confirm the match fits the documentation.
What HCC is P04.3?
P04.3 (newborn affected by maternal use of alcohol) 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 2026. It does not map to any RxHCC in the Part D prescription drug model.
Does P04.3 risk-adjust for Medicare Advantage payment?
Yes. When documented and reported on a Medicare Advantage encounter, P04.3 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.
