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J96.91 ICD-10-CM Code: Respiratory failure, unspecified with hypoxia

J96.91 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)

J96.91

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

Respiratory failure, unspecified with hypoxia

A condition where the lungs cannot provide enough oxygen to the blood, but whether it is acute or chronic is not specified.

Buddy the Bee presenting code insight

Buddy Insight

Respiratory failure with hypoxia indicates the lungs cannot adequately oxygenate the blood, signaling severe pulmonary compromise that directly increases mortality risk.

CMS-HCC V28

HCC 213

RAF 0.370

CMS-HCC V24

HCC 84

RAF 0.282

ACA/HHS

HCC 127

Varies by metal level

ESRD/PACE

HCC 84

RAF 0.061

RXHCC

N/A

—

Not mapped

Code Book Path

Official
J96Respiratory failure, not elsewhere classified
J96.9Respiratory failure, unspecified
J96.91Respiratory failure, unspecified with hypoxia

Inclusion Terms

Official

ICD-10-CM does not list inclusion terms for J96.91 in this effective period.

Excludes 2

Official

ICD-10-CM does not list Excludes 2 notes for J96.91 in this effective period.

Related Child Codes

Official
J96.90Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia
J96.92Respiratory failure, unspecified with hypercapnia

Includes

Official

ICD-10-CM does not list Includes notes for J96.91 in this effective period.

Excludes 1

Official

ICD-10-CM does not list Excludes 1 notes for J96.91 in this effective period.

Code First

Official

ICD-10-CM does not list Code First sequencing instructions for J96.91 in this effective period.

Use Additional

Official

ICD-10-CM does not list Use Additional Code instructions for J96.91 in this effective period.

Code Also

Official

ICD-10-CM does not list Code Also instructions for J96.91 in this effective period.

Buddy Documentation Tip

HCC Buddy guidance
Provider documentation explicitly stating 'respiratory failure with hypoxia'
Oxygen saturation levels or arterial blood gas results demonstrating hypoxemia (PaO2 < 60 mmHg or SpO2 < 90%)
Clinical context including underlying etiology (e.g., pneumonia, COPD exacerbation, pulmonary embolism)
Current treatment plan including supplemental oxygen delivery method and flow rate

MEAT Support

HCC Buddy guidance
Provider documentation explicitly stating 'respiratory failure with hypoxia'
Oxygen saturation levels or arterial blood gas results demonstrating hypoxemia (PaO2 < 60 mmHg or SpO2 < 90%)
Clinical context including underlying etiology (e.g., pneumonia, COPD exacerbation, pulmonary embolism)
Current treatment plan including supplemental oxygen delivery method and flow rate

Audit Caution

HCC Buddy guidance
Coding hypoxemia (R09.02) instead of respiratory failure — respiratory failure requires a higher clinical threshold with documented organ system failure
Failing to query the provider on acuity (acute vs. chronic) which would allow a more specific code
Assuming supplemental oxygen use alone constitutes respiratory failure — the provider must explicitly document 'respiratory failure'
Missing the opportunity to capture both hypoxia and hypercapnia when both are present (J96.92 or J96.99)

Common Mistakes

HCC Buddy guidance
J96.01 — Acute respiratory failure with hypoxia: use when acuity is clearly acute onset
J96.11 — Chronic respiratory failure with hypoxia: use when the condition is long-standing and chronic
J96.21 — Acute and chronic respiratory failure with hypoxia: use for acute-on-chronic presentations
J96.90 — Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia: even less specific, lacks the hypoxia qualifier

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 J96.91 an HCC code?

Yes. J96.91 (Respiratory failure, unspecified with hypoxia) 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: J96.91 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
J96.91
Description
Respiratory failure, unspecified with hypoxia
HCC (V28)
HCC 213 — Cardio-Respiratory Failure and Shock
RAF
0.370
Billable
Yes
Payment year
2026

HCC Category Mapping

V28HCC 213, Cardio-Respiratory Failure and Shock
0.370
V24HCC 84, Cardio-Respiratory Failure and Shock
0.282
ESRDHCC 84, Cardio-Respiratory Failure and Shock
0.061

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 J96.91 in the Code Book — tabular path, V28 RAF, and MEAT checklist →

MEAT Criteria for J96.91

For J96.91 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 J96.91 during that encounter, not just copy-forwarded from a problem list.

Coder workflow notes

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What This Code Means

J96.91 is the ICD-10-CM diagnosis code for respiratory failure, unspecified with hypoxia. A condition where the lungs cannot provide enough oxygen to the blood, but whether it is acute or chronic is not specified. J96.91 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, J96.91 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, J96.91 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.

Use only when respiratory failure with hypoxia is documented but the acuity (acute vs. chronic) cannot be determined from the record. Because J96.91 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 J96.91 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.

Coding Tips

  • •Use only when respiratory failure with hypoxia is documented but the acuity (acute vs. chronic) cannot be determined from the record
  • •Query the provider to clarify the onset and duration to assign a more specific code (J96.01 or J96.11)

Clinical Significance

Respiratory failure with hypoxia indicates the lungs cannot adequately oxygenate the blood, signaling severe pulmonary compromise that directly increases mortality risk. This diagnosis is critical for risk adjustment as it reflects a high-acuity condition requiring supplemental oxygen or mechanical ventilation. The unspecified acuity limits specificity and should prompt a provider query to distinguish acute from chronic presentation.

Documentation Requirements

  • ✓Provider documentation explicitly stating 'respiratory failure with hypoxia'
  • ✓Oxygen saturation levels or arterial blood gas results demonstrating hypoxemia (PaO2 < 60 mmHg or SpO2 < 90%)
  • ✓Clinical context including underlying etiology (e.g., pneumonia, COPD exacerbation, pulmonary embolism)
  • ✓Current treatment plan including supplemental oxygen delivery method and flow rate
  • ✓Whether the condition is acute, chronic, or acute-on-chronic (to support specificity query)

Commonly Confused Codes

  • •J96.01: Acute respiratory failure with hypoxia: use when acuity is clearly acute onset
  • •J96.11: Chronic respiratory failure with hypoxia: use when the condition is long-standing and chronic
  • •J96.21: Acute and chronic respiratory failure with hypoxia: use for acute-on-chronic presentations
  • •J96.90: Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia: even less specific, lacks the hypoxia qualifier
  • •R09.02: Hypoxemia: indicates low blood oxygen but does NOT meet the threshold of respiratory failure

Child Codes

J96.90Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia
HCC 213
J96.91Respiratory failure, unspecified with hypoxia
HCC 213
J96.92Respiratory failure, unspecified with hypercapnia
HCC 213

Code Hierarchy

└J96Respiratory failure, not elsewhere classified└J96.9Respiratory failure, unspecified└J96.91Respiratory failure, unspecified with hypoxia
└J96.91Respiratory failure, unspecified with hypoxia

Because J96.91 maps to a payment HCC, the documentation must also satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's risk adjustment score.

J96.91 maps to CMS-HCC V28 category 213, Cardio-Respiratory Failure and Shock. See the ICD-10 to HCC mapping hub for how the V28 crosswalk works. Because J96.91 carries a payment HCC, you can see what it adds to a RAF score and check the documentation the chart needs before it is submitted.

More on J96.91

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