What is ICD-10 code J95.04?

J95.04 is the ICD-10-CM diagnosis code for Tracheo-esophageal fistula following tracheostomy. An abnormal connection that develops between the windpipe and esophagus (food tube) as a complication of tracheostomy. It belongs to the ICD-10-CM chapter for diseases of the respiratory system (j00-j99). J95.04 is a billable code, meaning it can be reported on a claim as a primary or secondary diagnosis when supported by documentation. J95.04 is part of the FY2026 ICD-10-CM code set published by the CMS National Center for Health Statistics and used on Medicare, Medicaid, and commercial claims in the United States.

Yes. J95.04 is a billable ICD-10-CM code that can be reported on professional and institutional claims as a primary or secondary diagnosis when the provider documentation supports the specific condition described. Billable codes in ICD-10-CM are coded to the highest level of specificity available for the documented diagnosis. J95.04 is current for fiscal year 2026 and remains in the active CMS ICD-10-CM code set published by the National Center for Health Statistics.

Which HCC does J95.04 map to under V28?

J95.04 maps to CMS-HCC V28 HCC 211 (Respirator Dependence/Tracheostomy Status/Complications). The category numbers, labels, and conditions come from the CMS-HCC V28 model file for payment year 2026.

2026 ICD-10-CM J95.04: Tracheo-esophageal fistula

J95.04 maps to CMS-HCC V28 211. A source-labeled RAF reference is available. Documentation must support MEAT. MEAT criteria · RAF Calculator · HCC Buddy coding tools

ICD-10-CM Code View

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Code lookupJ95.04Effective periodFY2026 Apr Update (Apr 1-Sep 30)

FY 2026 Apr update / Diseases of the respiratory system (J00-J99) / Intraoperative and postprocedural complications and disorders of respiratory system, not elsewhere classified (J95)

J95.04

Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidance

Tracheo-esophageal fistula following tracheostomy

An abnormal connection that develops between the windpipe and esophagus (food tube) as a complication of tracheostomy.

Buddy Insight

CMS-HCC V28

Mapped

HCC 211

Respirator Dependence/Tracheo...

Code-level coefficient reference

CMS-HCC V24

Historical

Not used for standard CY2026 Medicare Advantage payment. Select a historical period to review V24.

Not used for CY2026 payment

ACA/HHS

Mapped

HCC 125

HHS-HCC 125 adult, RAF varies...

Code-level coefficient reference

ESRD/PACE

Mapped

HCC 82

Respirator Dependence/Tracheo...

Code-level coefficient reference

RXHCC

N/A

—

Not risk-adjusted for this model/period.

Not mapped

Code Book Path

Official

J95Intraoperative and postprocedural complications and disorders of respiratory system, not elsewhere classified

J95.0Tracheostomy complications

J95.04Tracheo-esophageal fistula following tracheostomy

Inclusion Terms

Official

ICD-10-CM does not list inclusion terms for J95.04 in this effective period.

Excludes 2

Official

ICD-10-CM does not list Excludes 2 notes for J95.04 in this effective period.

Related Child Codes

Official

J95.00Unspecified tracheostomy complication

J95.01Hemorrhage from tracheostomy stoma

J95.02Infection of tracheostomy stoma

J95.03Malfunction of tracheostomy stoma

J95.09Other tracheostomy complication

Includes

Official

ICD-10-CM does not list Includes notes for J95.04 in this effective period.

Excludes 1

Official

ICD-10-CM does not list Excludes 1 notes for J95.04 in this effective period.

Code First

Official

ICD-10-CM does not list Code First sequencing instructions for J95.04 in this effective period.

Use Additional

Official

ICD-10-CM does not list Use Additional Code instructions for J95.04 in this effective period.

Code Also

Official

ICD-10-CM does not list Code Also instructions for J95.04 in this effective period.

Buddy Documentation Tip

HCC Buddy guidance

Imaging or endoscopic confirmation of tracheo-esophageal fistula (esophagram, bronchoscopy, CT scan)

Documentation linking the fistula to the tracheostomy (not congenital or malignancy-related)

Clinical manifestations (recurrent aspiration, air in the stomach during mechanical ventilation, coughing with swallowing)

Treatment plan including surgical repair and nutritional management

MEAT Support

HCC Buddy guidance

Imaging or endoscopic confirmation of tracheo-esophageal fistula (esophagram, bronchoscopy, CT scan)

Documentation linking the fistula to the tracheostomy (not congenital or malignancy-related)

Clinical manifestations (recurrent aspiration, air in the stomach during mechanical ventilation, coughing with swallowing)

Treatment plan including surgical repair and nutritional management

Audit Caution

HCC Buddy guidance

Using the unspecified or malfunction codes when a tracheo-esophageal fistula is specifically documented

Confusing acquired TEF from tracheostomy with congenital TEF which has different coding

Failing to link the fistula causally to the tracheostomy procedure in documentation

Not coding associated complications such as aspiration pneumonia, malnutrition, or recurrent infections separately

Common Mistakes

HCC Buddy guidance

Q39.1 — Atresia of esophagus with tracheo-esophageal fistula is a congenital condition, not acquired

J95.03 — Malfunction of tracheostomy stoma is a functional problem without structural fistula

J95.00 — Unspecified tracheostomy complication should not be used when TEF is specifically documented

K22.8 — Other specified diseases of esophagus may capture esophageal pathology but does not specify the tracheal communication

Current with CMS: FY2026 ICD-10-CM Apr 1 update (effective Apr 1 – Sep 30, 2026) · CMS-HCC V28, 100% phased in for payment year 2026. FY2027 code set already staged for October 1, 2026. How HCC Buddy stays current →

Is J95.04 an HCC code?

Yes. J95.04 (Tracheo-esophageal fistula following tracheostomy) maps to HCC 211, Respirator Dependence/Tracheostomy Status/Complications under the CMS-HCC V28 risk adjustment model, with a source-labeled community non-dual aged reference coefficient of 0.879. Source-labeled code-level coefficients are references, not member totals. Actual contribution depends on complete member context, hierarchy and cleanup rules, interactions, and model year. HCC Buddy's RAF Calculator supports CMS-HCC V28 PY2026 and shows no score unless every required source and calculation check passes. It is billable for payment year 2026.

Coder answer: J95.04 is billable and maps to V28 HCC 211, Respirator Dependence/Tracheostomy Status/Complications. Open it in the Code Book for the tabular path, RAF, and MEAT checklist.

Code: J95.04
Description: Tracheo-esophageal fistula following tracheostomy
HCC (V28): HCC 211 — Respirator Dependence/Tracheostomy Status/Complications
RAF reference coefficient: 0.879
Billable: Yes
Payment year: 2026

HCC Category Mapping

V28HCC 211, Respirator Dependence/Tracheostomy Status/Complications

0.879

ESRDHCC 82, Respirator Dependence/Tracheostomy Status

Not separately weighted

These are source-labeled model coefficients, not member totals. A category may still be removed by hierarchy or model cleanup rules. Weights are not directly comparable across models: CMS-HCC V28 and V24 use Community, Non-Dual, Aged; ESRD uses the dialysis continuing-enrollee model; RxHCC is the Part D continuing-enrollee, non-low-income, aged weight (a larger scale than CMS-HCC). ACA/HHS has no single weight — it varies by metal level. Actual per-patient RAF contribution depends on member context, hierarchy and cleanup rules, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains available for historical review.

Work J95.04 in the Code Book — tabular path, V28 RAF reference, and MEAT checklist →

MEAT Criteria for J95.04

For J95.04 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 J95.04 during that encounter, not just copy-forwarded from a problem list.

Coder workflow notes

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What This Code Means

J95.04 is the ICD-10-CM diagnosis code for tracheo-esophageal fistula following tracheostomy. An abnormal connection that develops between the windpipe and esophagus (food tube) as a complication of tracheostomy. J95.04 sits in the ICD-10-CM chapter for diseases of the respiratory system (j00-j99), within the section covering intraoperative and postprocedural complications and disorders of respiratory system, not elsewhere classified (j95).

Under the CMS-HCC V28 risk adjustment model, J95.04 maps to Respirator Dependence/Tracheostomy Status/Complications (HCC 211) with a source-labeled community, non-dual, aged reference coefficient of 0.879. No V24 mapping is shown for J95.04; use the applicable model and payment year when reviewing the V28 mapping. 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. Source-labeled code-level coefficients are references, not member totals. Actual contribution depends on complete member context, hierarchy and cleanup rules, interactions, and model year. HCC Buddy's RAF Calculator supports CMS-HCC V28 PY2026 and shows no score unless every required source and calculation check passes.

This is a serious complication requiring careful documentation of when it was diagnosed. Because J95.04 maps to an HCC category, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) before the diagnosis is used for risk adjustment. 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, source-labeled coefficient references, and MEAT documentation criteria for J95.04 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.

Coding Tips

•This is a serious complication requiring careful documentation of when it was diagnosed
•Ensure the fistula is documented as a direct result of the tracheostomy procedure

Clinical Significance

Tracheo-esophageal fistula following tracheostomy is a serious acquired complication where an abnormal communication develops between the trachea and esophagus as a result of tracheostomy tube pressure or erosion. This leads to aspiration of gastric and esophageal contents into the airway, causing recurrent infections and nutritional compromise. Surgical repair is typically required and carries significant morbidity.

Documentation Requirements

✓Imaging or endoscopic confirmation of tracheo-esophageal fistula (esophagram, bronchoscopy, CT scan)
✓Documentation linking the fistula to the tracheostomy (not congenital or malignancy-related)
✓Clinical manifestations (recurrent aspiration, air in the stomach during mechanical ventilation, coughing with swallowing)
✓Treatment plan including surgical repair and nutritional management
✓Assessment of tracheostomy tube positioning and cuff management

Commonly Confused Codes

•Q39.1: Atresia of esophagus with tracheo-esophageal fistula is a congenital condition, not acquired
•J95.03: Malfunction of tracheostomy stoma is a functional problem without structural fistula
•J95.00: Unspecified tracheostomy complication should not be used when TEF is specifically documented
•K22.8: Other specified diseases of esophagus may capture esophageal pathology but does not specify the tracheal communication