ICD-10 D43.1
Billable / Specific HCC v28: 12Neoplasm of uncertain behavior of brain, infratentorial
About ICD-10-CM D43.1
ICD-10-CM code D43.1 represents Neoplasm of uncertain behavior of brain, infratentorial. This is a billable/specific code in the Neoplasms chapter (block D43). The 2026 edition of ICD-10-CM D43.1 became effective on October 1, 2025.
Coding Tips for D43.1
Specialist guidance from the PayerReady Medical Coding Team. Specificity warnings, HCC capture rules, sequencing notes.
D43.1 is a CMS-HCC v28 risk-adjustment code (category 12). To count for the patient Risk Adjustment Factor (RAF), document the diagnosis with MEAT language each calendar year: Monitored, Evaluated, Assessed, Treated. A diagnosis on the problem list alone does not satisfy CMS RADV audit standards. Include the diagnosis in the assessment with current status and current treatment plan.
Inclusion Terms / Approximate Synonyms
Clinical terms and conditions classified under D43.1. Per CMS ICD-10-CM Tabular 2026.
- Neoplasm of uncertain behavior of brain stem
- Neoplasm of uncertain behavior of cerebellum
- Neoplasm of uncertain behavior of fourth ventricle
Medicare Advantage HCC Impact
Capture this diagnosis annually for accurate risk adjustment. Missed HCC captures are the #1 revenue leak in Medicare Advantage risk programs.
Medicare LCD Coverage for D43.1
Local Coverage Determinations (LCDs) from CMS MACs that list D43.1 as a covered diagnosis.
Showing top 10 of 358 total . Click a CPT for full coverage scope.
Commercial Payer Coverage
Coverage policies from major commercial payers referencing D43.1.
1 Cigna
5 Medicare
CPT Codes Commonly Billed with D43.1
Procedures frequently paired with this diagnosis based on PayerReady's Dx↔Px linkage data.
- 95926 CMS LCD: Billing and Coding: Somatosensory Testing CMS LCD
- 95925 CMS LCD: Billing and Coding: Somatosensory Testing CMS LCD
- 95938 CMS LCD: Billing and Coding: Somatosensory Testing CMS LCD
- 95927 CMS LCD: Billing and Coding: Somatosensory Testing CMS LCD
- 95940 CMS LCD: Billing and Coding: Intraoperative Neurophysiological Testing CMS LCD
- G0453 CMS LCD: Billing and Coding: Intraoperative Neurophysiological Testing CMS LCD
- 92571 CMS LCD: Billing and Coding: Vestibular and Audiologic Function Studies CMS LCD
- 92568 CMS LCD: Billing and Coding: Vestibular and Audiologic Function Studies CMS LCD
- 92620 CMS LCD: Billing and Coding: Vestibular and Audiologic Function Studies CMS LCD
- 92588 CMS LCD: Billing and Coding: Vestibular and Audiologic Function Studies CMS LCD
Convert D43.1 to ICD-9-CM
Per CMS General Equivalence Mappings (GEMs), useful for legacy data review and historical claim analysis.
| ICD-10 | ICD-9 | Mapping Flags |
|---|---|---|
| D43.1 | 2375 | 10000 |
Flags format (5 digits): Approximate · No Map · Combination · Scenario · Choice List. Source: CMS 2017 GEMs (final version).
Codes Adjacent To D43.1
Other codes in section D37-D48 (Neoplasms of uncertain behavior, polycythemia vera and myelodysplastic syndromes).
ICD-10 D43.1, Billing FAQ
Is ICD-10 code D43.1 billable? +
Yes, D43.1 is a billable ICD-10-CM code that can appear as a primary or secondary diagnosis on claims.
What other names or terms map to D43.1? +
ICD-10 D43.1 includes: Neoplasm of uncertain behavior of brain stem; Neoplasm of uncertain behavior of cerebellum; Neoplasm of uncertain behavior of fourth ventricle.
Does D43.1 affect Medicare Advantage HCC risk adjustment? +
Yes. D43.1 maps to CMS-HCC v28 category 12. Capture this diagnosis annually for accurate Medicare Advantage risk score.
What CPT codes are commonly billed with D43.1? +
Procedures frequently paired with D43.1 include: 95926, 95925, 95938, 95927, 95940.
What ICD-9 codes does D43.1 map to? +
Per CMS GEMs, D43.1 maps to ICD-9 codes: 2375. Useful for legacy data review and historical claim analysis.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on June 1, 2026.
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