J96.11 ICD-10-CM Code: Chronic respiratory failure with hypoxia
J96.11 maps to CMS-HCC V28 213. A source-labeled RAF reference is available. Confirm the documented diagnosis and applicable coding requirements. MEAT criteria · RAF Calculator · free HCC coding tools
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FY 2026 Apr update / Diseases of the respiratory system (J00-J99) / Other diseases of the respiratory system (J96-J99)
J96.11
Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidanceChronic respiratory failure with hypoxia
A long-term condition where the lungs cannot provide enough oxygen to the blood over an extended period.
Buddy Insight
Chronic respiratory failure with hypoxia indicates long-term inability to maintain adequate blood oxygen levels, typically requiring continuous supplemental oxygen therapy.
CMS-HCC V28
MappedHCC 213
Coefficient HCC 213: 0.370 (Community Non-Dual Aged (CNA))
CMS-HCC V24
HistoricalHistorical
Not used for CY2026 payment
ACA/HHS
MappedHCC 127
Code-level coefficient reference
ESRD/PACE
MappedHCC 84
Code-level coefficient reference
RXHCC
N/A—
Not mapped
Code Book Path
Inclusion Terms
OfficialNo inclusion terms are included in this display for J96.11. Check the code and parent instructions in the Code Book.
Excludes 2
Official- certain conditions originating in the perinatal period (P04-P96)Inherited from J00-J99
- certain infectious and parasitic diseases (A00-B99)Inherited from J00-J99
- complications of pregnancy, childbirth and the puerperium (O00-O9A)Inherited from J00-J99
- congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)Inherited from J00-J99
- endocrine, nutritional and metabolic diseases (E00-E88)Inherited from J00-J99
- injury, poisoning and certain other consequences of external causes (S00-T88)Inherited from J00-J99
- neoplasms (C00-D49)Inherited from J00-J99
- smoke inhalation (T59.81-)Inherited from J00-J99
- symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)Inherited from J00-J99
Related Codes
Includes
OfficialNo Includes notes are included in this display for J96.11. Check the code and parent instructions in the Code Book.
Excludes 1
Official- acute respiratory distress syndrome (J80)Inherited from J96
- cardiorespiratory failure (R09.2)Inherited from J96
- newborn respiratory distress syndrome (P22.0)Inherited from J96
- postprocedural respiratory failure (J95.82-)Inherited from J96
- respiratory arrest (R09.2)Inherited from J96
- respiratory arrest of newborn (P28.81)Inherited from J96
- respiratory failure of newborn (P28.5)Inherited from J96
Code First
OfficialNo Code First sequencing instructions are included in this display for J96.11. Check the code and parent instructions in the Code Book.
Use Additional
Official- code, where applicable, to identify:Inherited from J00-J99
- exposure to environmental tobacco smoke (Z77.22)Inherited from J00-J99
- exposure to tobacco smoke in the perinatal period (P96.81)Inherited from J00-J99
- history of tobacco dependence (Z87.891)Inherited from J00-J99
- occupational exposure to environmental tobacco smoke (Z57.31)Inherited from J00-J99
- tobacco dependence (F17.-)Inherited from J00-J99
- tobacco use (Z72.0)Inherited from J00-J99
Code Also
OfficialNo Code Also instructions are included in this display for J96.11. Check the code and parent instructions in the Code Book.
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 J96.11 an HCC code?
Yes. J96.11 (Chronic respiratory failure with hypoxia) maps to HCC 213, Cardio-Respiratory Failure and Shock under the CMS-HCC V28 risk adjustment model, with a source-labeled community non-dual aged reference coefficient of 0.370. 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: J96.11 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
- J96.11
- Description
- Chronic 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 J96.11 in the Code Book — tabular path, V28 RAF reference, and MEAT checklist →
MEAT review for J96.11
For J96.11, confirm that the documentation supports the diagnosis and meets the applicable coding, encounter, program and payer requirements. MEAT (Monitor, Evaluate, Assess, or Treat) is a review mnemonic, not a universal CMS coding rule.
- 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
Coder workflow notes
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What This Code Means
J96.11 is the ICD-10-CM diagnosis code for chronic respiratory failure with hypoxia. A long-term condition where the lungs cannot provide enough oxygen to the blood over an extended period. J96.11 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, J96.11 maps to Cardio-Respiratory Failure and Shock (HCC 213) with a source-labeled community, non-dual, aged reference coefficient of 0.370. For CY2026 non-PACE Medicare Advantage, CMS uses 100% of the 2024 CMS-HCC model (V28). PACE uses a separate model blend. 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.
Requires documentation of chronic respiratory failure with confirmed hypoxia; verify ABG results showing low pO2. For J96.11, confirm that the documentation supports the diagnosis and meets the applicable coding, encounter, program and payer requirements. MEAT (Monitor, Evaluate, Assess, or Treat) is a review mnemonic, not a universal CMS coding rule. 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 J96.11 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Requires documentation of chronic respiratory failure with confirmed hypoxia; verify ABG results showing low pO2
- •Common in patients with COPD, interstitial lung disease, or neuromuscular disorders; ensure chronicity is documented
Clinical Significance
Chronic respiratory failure with hypoxia indicates long-term inability to maintain adequate blood oxygen levels, typically requiring continuous supplemental oxygen therapy. This is most commonly seen in advanced COPD, severe interstitial lung disease, and pulmonary hypertension. These patients have high utilization including home oxygen, pulmonary rehabilitation, and frequent monitoring.
Documentation Requirements
- ✓Provider documentation confirming chronic respiratory failure with hypoxia
- ✓ABG or pulse oximetry showing chronic hypoxemia (PaO2 consistently < 60 mmHg or SpO2 < 88%)
- ✓Documentation of home oxygen therapy and flow requirements
- ✓Underlying cause documented and coded separately
- ✓Functional status assessment related to the chronic hypoxemic respiratory failure
Commonly Confused Codes
- •J96.10: Chronic respiratory failure unspecified should not be used when hypoxia is documented
- •J96.12: Chronic respiratory failure with hypercapnia is for CO2 retention, not low oxygen
- •J96.01: Acute respiratory failure with hypoxia is for sudden onset, not chronic
- •J96.21: Acute and chronic respiratory failure with hypoxia is for acute decompensation of chronic failure