2027 ICD-10-CM Diagnosis Code P04.9Newborn affected by maternal noxious substance, unspecified
P04.9 is a billable ICD-10-CM diagnosis code for newborn affected by maternal noxious substance, unspecified. 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 noxious substance 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, P04.9 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
Code Classification
Medicare Risk Adjustment (HCC)Billing
P04.9 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.
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 noxious substance transmitted via breast milk
- Neonatal disorder caused by substance transmitted via breast milk
- Neonatal hyperbilirubinemia caused by substance transmitted from mother
- Neonatal jaundice caused by substance transmitted via breast milk
Instructional NotesGuidance
Instructions from the official ICD-10-CM Tabular List that apply to P04.9: its own notes plus those printed at 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.
- nonteratogenic effects of substances transmitted via placenta
- 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
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.
- 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.-)
Code First
The underlying condition named in the note is sequenced before this code.
- any current condition in newborn, if applicable
Notes
General instructions on how these codes are used.
- 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).
- 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 P04.9, its category, or a range that includes it.
Excludes2 3
These codes carry an Excludes2 note naming P04.9: 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 pregnancynewborn affected by noxious substances transmitted via placenta or breast milk (P04.-) names P04.-, which includes this code
- Q86 Congenital malformation syndromes due to known exogenous causes, not elsewhere classifiednonteratogenic 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 healthnewborn affected by noxious substances transmitted via placenta or breast milk (P04.-) names P04.-, which includes this code
Index to Diseases and InjuriesGuidance
Clinical ClassificationClinical
AHRQ’s CCSR groups this code into broader clinical categories.
Patient EducationClinical
Pregnancy and Substance Use
During pregnancy, there are many things you can do to keep yourself and your baby healthy. They include getting regular prenatal care, eating healthy, and staying active. But it's also very important to avoid substances that could be harmful to you and your baby, such as tobacco, alcohol, and drugs.
Read the full article at MedlinePlus
Courtesy of MedlinePlus, a service of the U.S. National Library of Medicine.
Convert P04.9 to ICD-9-CMHistory
Code HistoryHistory
Questions About P04.9Overview
What is the ICD-10 code for newborn affected by maternal noxious substance, unspecified?
The ICD-10-CM code for newborn affected by maternal noxious substance, unspecified is P04.9 (sometimes written as P049). It is billable on HIPAA-covered claims from October 1, 2026 through September 30, 2027.
Is P04.9 a billable code?
Yes. This is a billable ICD-10-CM code, specific enough to report newborn affected by maternal noxious substance, unspecified on HIPAA-covered claims from October 1, 2026 through September 30, 2027.
What MS-DRG does P04.9 group to?
When newborn affected by maternal noxious substance, unspecified 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.
What is coded first with P04.9?
The Code First note at P04, which applies to P04.9, reads: any current condition in newborn, if applicable. When one of these applies, it is sequenced before P04.9.
What is the ICD-9 equivalent of P04.9?
Under the General Equivalence Mappings, newborn affected by maternal noxious substance, unspecified converts to ICD-9-CM 760.70 (nox sub NOS aff NB/fetus) and 760.79 (nox sub NEC aff NB/fetus). The mapping is approximate, so confirm the match fits the documentation.
What HCC is P04.9?
P04.9 (newborn affected by maternal noxious substance, unspecified) 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 P04.9 risk-adjust for Medicare Advantage payment?
Yes. When documented and reported on a Medicare Advantage encounter, P04.9 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.
