G95.81
BillableConus medullaris syndrome
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is G95.81 an HCC code?
Yes. G95.81 maps to Spinal Cord Disorders/Injuries under the CMS-HCC V28 risk adjustment model (and Spinal Cord Disorders/Injuries 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 G95.81
For G95.81 to 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 G95.81 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
G95.81 is the ICD-10-CM diagnosis code for conus medullaris syndrome. A syndrome affecting the lowest part of the spinal cord (conus medullaris) that causes loss of bowel and bladder control, sexual dysfunction, and leg weakness. G95.81 sits in the ICD-10-CM chapter for diseases of the nervous system (g00-g99), within the section covering other disorders of the nervous system (g89-g99).
Under the CMS-HCC V28 risk adjustment model, G95.81 maps to Spinal Cord Disorders/Injuries (HCC 182) with a community, non-dual, aged base RAF weight of 0.282. Under the older V24 model, G95.81 mapped to the same category but with a base RAF weight of 0.464 — V28 recalibrated weights across the entire model. 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.
Identify the underlying cause (trauma, tumor, disc herniation) and code separately. Because G95.81 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 G95.81 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Identify the underlying cause (trauma, tumor, disc herniation) and code separately
- •Document specific neurological deficits including bowel/bladder dysfunction and lower extremity weakness
Clinical Significance
Conus medullaris syndrome results from damage to the terminal end of the spinal cord (conus medullaris), typically at the T12-L2 vertebral level, causing a characteristic pattern of lower motor neuron dysfunction in the legs, bowel and bladder dysfunction, and saddle anesthesia. It is distinguished from cauda equina syndrome by its more symmetric presentation and upper motor neuron signs. This condition requires urgent diagnosis and treatment to prevent permanent neurological damage.
Documentation Requirements
- ✓MRI demonstrating pathology at the conus medullaris (T12-L2 vertebral level)
- ✓Neurological examination documenting symmetric lower extremity weakness, saddle anesthesia, and sphincter dysfunction
- ✓Identification of the underlying cause (disc herniation, tumor, vascular event, trauma)
- ✓Bowel and bladder function assessment
- ✓Treatment plan and surgical intervention details if applicable