C7A.095
BillableMalignant carcinoid tumor of the midgut, unspecified
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is C7A.095 an HCC code?
Yes. C7A.095 maps to Lymphoma and Other Cancers under the CMS-HCC V28 risk adjustment model (and Breast, Prostate, and Other Cancers and Tumors under V24).
HCC Category Mapping
RAF weights shown are the community, non-dual, aged base weights from the CMS risk adjustment model file. Actual per-patient RAF contribution depends on member segment, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains in use during the transition and for historical data.
MEAT Criteria for C7A.095
For C7A.095to count as a valid HCC diagnosis in a given encounter, the provider's documentation must show MEAT: Monitor, Evaluate, Assess, or Treat. A diagnosis from a prior year does not carry forward automatically — it has to be re-documented and supported each calendar year.
- MMonitor: signs, symptoms, disease progression, or lab trending documented in the note
- EEvaluate: test results, medication response, or physical findings reviewed by the provider
- AAssess: explicit mention in the assessment or plan with acknowledgment of status
- TTreat: medication, referral, procedure, therapy, or counseling tied to the diagnosis
Only one of M/E/A/T is required to support the code, but the documentation must be specific enough to show that the provider actually addressed C7A.095 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
C7A.095 is the ICD-10-CM diagnosis code for malignant carcinoid tumor of the midgut, unspecified. A rare cancer that starts in hormone-producing cells of the middle section of the small intestine (midgut). This type of cancer grows slowly and can spread to other parts of the body. C7A.095 sits in the ICD-10-CM chapter for neoplasms (c00-d49), within the section covering malignant neuroendocrine tumors (c7a).
Under the CMS-HCC V28 risk adjustment model, C7A.095 maps to Lymphoma and Other Cancers (HCC 21) with a community, non-dual, aged base RAF weight of 0.671. Under the older CMS-HCC V24 model, C7A.095 maps to Breast, Prostate, and Other Cancers and Tumors (HCC 12) with a community, non-dual, aged base RAF weight of 0.150. V28 is the CMS-HCC risk adjustment model that reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition.
Verify the exact location of the carcinoid tumor in the midgut (duodenum, jejunum, or ileum) as more specific codes may be available if documentation specifies the site. Because C7A.095 maps to a payment HCC, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's Medicare Advantage risk adjustment score. When documentation is ambiguous, coders should issue a provider query rather than assume the highest-specificity variant.
HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for C7A.095 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Verify the exact location of the carcinoid tumor in the midgut (duodenum, jejunum, or ileum) as more specific codes may be available if documentation specifies the site
- •Ensure the neoplasm is documented as malignant and originating in the midgut; carcinoid tumors in other GI locations have different codes
Clinical Significance
Malignant carcinoid tumor of the midgut represents a neuroendocrine malignancy originating in midgut-derived structures (distal duodenum, jejunum, ileum, appendix, ascending colon) when the specific site cannot be determined. Midgut carcinoids are the most common type of gastrointestinal carcinoid and are most likely to produce classic carcinoid syndrome with serotonin-mediated flushing, diarrhea, and right-sided cardiac valvular disease. They frequently metastasize to mesenteric lymph nodes and liver.
Documentation Requirements
- ✓Pathology confirming neuroendocrine/carcinoid histology
- ✓Documentation that the specific midgut site cannot be determined
- ✓24-hour urine 5-HIAA levels or serum serotonin levels
- ✓Imaging for mesenteric lymph node and liver metastases
- ✓Echocardiogram results if carcinoid syndrome is present (carcinoid heart disease screening)
- ✓Current treatment (somatostatin analogs, targeted therapy, surgery)
Commonly Confused Codes
- •C7A.010-C7A.012 — Site-specific small intestine carcinoid codes: Use these when duodenum, jejunum, or ileum is specifically identified
- •C7A.020 — Malignant carcinoid tumor of the appendix: Use when the appendix is specifically documented
- •C7A.094 — Malignant carcinoid tumor of the foregut, unspecified: Foregut includes proximal structures above the ligament of Treitz
- •C7A.096 — Malignant carcinoid tumor of the hindgut, unspecified: Hindgut includes distal colon and rectum