J96.01 ICD-10-CM Code: Acute respiratory failure with hypoxia

Code

J96.01

Description

Acute respiratory failure with hypoxia

HCC (V28)

HCC 213 — Cardio-Respiratory Failure and Shock

RAF reference coefficient

0.370

Billable

Yes

Payment year

2026

HCC Category Mapping

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 J96.01 in the Code Book — tabular path, V28 RAF reference, and MEAT checklist →

MEAT review for J96.01

What This Code Means

HCC Buddy maintains structured V28 and V24 mapping, source-labeled coefficient references, and MEAT documentation criteria for J96.01 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.

Coding Tips

• •This code requires documentation of acute onset and confirmed hypoxia (low blood oxygen); verify arterial blood gas (ABG) results in the medical record
• •Do not use this code if the respiratory failure is chronic or if hypercapnia (high CO2) is the primary concern instead

Clinical Significance

Acute respiratory failure with hypoxia is a life-threatening condition where the lungs cannot maintain adequate blood oxygen levels. This is the most common form of respiratory failure, often caused by pneumonia, ARDS, pulmonary embolism, or acute exacerbation of chronic lung disease. The specific documentation of hypoxia (Type 1 respiratory failure) guides treatment with oxygen supplementation and positive-pressure ventilation.

Documentation Requirements

• ✓Provider documentation explicitly stating acute respiratory failure with hypoxia
• ✓ABG results showing PaO2 < 60 mmHg on room air or clinical evidence of severe hypoxemia
• ✓Documentation of acute onset (not chronic or acute-on-chronic)
• ✓Underlying cause identified and coded separately
• ✓Treatment plan including oxygen delivery method, FiO2, ventilatory support if needed

Commonly Confused Codes

• •J96.02: Acute respiratory failure with hypercapnia is Type 2 failure with high CO2, not low oxygen
• •J96.00: Acute respiratory failure unspecified should not be used when hypoxia is clearly documented
• •J96.11: Chronic respiratory failure with hypoxia is for long-standing, not acute, hypoxemic failure
• •J96.21: Acute and chronic respiratory failure with hypoxia is for patients with baseline chronic failure experiencing acute worsening

Child Codes