J96.10 ICD-10-CM Code: Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.10 maps to CMS-HCC V28 213 (RAF 0.370). Documentation must support MEAT. MEAT criteria · RAF calculator · HCC coding software
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FY 2026 Apr update / Diseases of the respiratory system (J00-J99) / Other diseases of the respiratory system (J96-J99)
J96.10
Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidanceChronic respiratory failure, unspecified whether with hypoxia or hypercapnia
A long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide, but the specific gas imbalance (low oxygen or high CO2) is not documented.
Buddy Insight
Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, indicates long-term inability of the lungs to maintain adequate gas exchange.
CMS-HCC V28
MappedHCC 213
RAF 0.370
CMS-HCC V24
MappedHCC 84
RAF 0.282
ACA/HHS
MappedHCC 127
Varies by metal level
ESRD/PACE
MappedHCC 84
RAF 0.061
RXHCC
N/A—
Not mapped
Code Book Path
Inclusion Terms
OfficialICD-10-CM does not list inclusion terms for J96.10 in this effective period.
Excludes 2
OfficialICD-10-CM does not list Excludes 2 notes for J96.10 in this effective period.
Related Child Codes
Includes
OfficialICD-10-CM does not list Includes notes for J96.10 in this effective period.
Excludes 1
OfficialICD-10-CM does not list Excludes 1 notes for J96.10 in this effective period.
Code First
OfficialICD-10-CM does not list Code First sequencing instructions for J96.10 in this effective period.
Use Additional
OfficialICD-10-CM does not list Use Additional Code instructions for J96.10 in this effective period.
Code Also
OfficialICD-10-CM does not list Code Also instructions for J96.10 in this effective period.
Buddy Documentation Tip
MEAT Support
Audit Caution
Common Mistakes
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 J96.10 an HCC code?
Yes. J96.10 (Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia) maps to Cardio-Respiratory Failure and Shock under the CMS-HCC V28 risk adjustment model (and Cardio-Respiratory Failure and Shock under V24), with a community non-dual aged RAF of 0.370. It is billable for payment year 2026.
Coder answer: J96.10 is billable and maps to V28 HCC 213, Cardio-Respiratory Failure and Shock. Open it in the Code Book for the tabular path, RAF, and MEAT checklist.
- Code
- J96.10
- Description
- Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
- HCC (V28)
- HCC 213 — Cardio-Respiratory Failure and Shock
- RAF
- 0.370
- Billable
- Yes
- Payment year
- 2026
HCC Category Mapping
Each model's RAF is its CMS base weight for that model's standard population, so 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 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.
Work J96.10 in the Code Book — tabular path, V28 RAF, and MEAT checklist →
MEAT Criteria for J96.10
For J96.10 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 J96.10 during that encounter, not just copy-forwarded from a problem list.
Coder workflow notes
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What This Code Means
J96.10 is the ICD-10-CM diagnosis code for chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. A long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide, but the specific gas imbalance (low oxygen or high CO2) is not documented. J96.10 sits in the ICD-10-CM chapter for diseases of the respiratory system (j00-j99), within the section covering other diseases of the respiratory system (j96-j99).
Under the CMS-HCC V28 risk adjustment model, J96.10 maps to Cardio-Respiratory Failure and Shock (HCC 213) with a community, non-dual, aged base RAF weight of 0.370. Under the older V24 model, J96.10 mapped to the same category but with a base RAF weight of 0.282, 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.
Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, documentation of chronic resp failure requiring ongoing oxygen, BiPAP, or ventilatory support. The provider must explicitly establish the chronic nature. Because J96.10 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 J96.10 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, documentation of chronic resp failure requiring ongoing oxygen, BiPAP, or ventilatory support. The provider must explicitly establish the chronic nature.
- •Do not confuse with J96.90 (unspecified acute or chronic respiratory failure). J96.10 is explicitly chronic; if acuity is unclear, query the provider.
- •V28 HCC 213 (Cardio-Respiratory Failure and Shock), a separate HCC from COPD. Chronic resp failure on top of COPD is a dual-HCC scenario worth catching.
Clinical Significance
Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, indicates long-term inability of the lungs to maintain adequate gas exchange. These patients require ongoing oxygen therapy, monitoring, and often home ventilatory support. The chronic nature reflects a permanent reduction in respiratory reserve that increases vulnerability to acute decompensation and drives significant ongoing healthcare utilization.
Documentation Requirements
- ✓Provider documentation confirming chronic respiratory failure (not just acute or unspecified)
- ✓Evidence of chronicity (present across multiple encounters, stable baseline of impaired gas exchange)
- ✓Underlying cause documented and coded (COPD, interstitial lung disease, neuromuscular disease)
- ✓Current treatment regimen including oxygen therapy, ventilatory support
- ✓Query for hypoxia or hypercapnia specification if ABG data is available
Commonly Confused Codes
- •J96.11: Chronic respiratory failure with hypoxia should be used when chronic hypoxemia is documented
- •J96.12: Chronic respiratory failure with hypercapnia should be used when chronic CO2 retention is documented
- •J96.00: Acute respiratory failure unspecified is for acute, not chronic, presentations
- •J96.20: Acute and chronic respiratory failure is for patients with chronic failure experiencing acute worsening