Q95.3
BillableBalanced sex/autosomal rearrangement in abnormal individual
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is Q95.3 an HCC code?
No. Q95.3 is a billable ICD-10-CM code but does not map to any HCC category in V28, V24, ESRD, or RxHCC.
HCC Category Mapping
RAF weights shown are the community, non-dual, aged base weights from the CMS risk adjustment model file. 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.
MEAT Criteria for Q95.3
For Q95.3to 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 Q95.3 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
Q95.3 is the ICD-10-CM diagnosis code for balanced sex/autosomal rearrangement in abnormal individual. A person with a balanced rearrangement involving both sex chromosomes and regular chromosomes who has abnormal physical features or health conditions. Q95.3 sits in the ICD-10-CM chapter for congenital malformations, deformations, chromosomal abnormalities, and genetic disorders (q00-qa0), within the section covering chromosomal abnormalities, not elsewhere classified (q90-q99).
Q95.3 is a billable ICD-10-CM code but does not map to a payment HCC under the CMS-HCC V28, V24, ESRD, or RxHCC risk adjustment models. It can be reported on Medicare Advantage encounter data submissions but it does not contribute to a beneficiary's RAF score and therefore does not affect risk-adjusted payments to the plan.
This code maps to RxHCC 148 (Mild Intellectual Disabilities) with a RAF weight of 0.0 in the RxHCC model. Although it doesn't affect risk adjustment scoring, it identifies patients with complex balanced rearrangements who may require medications for associated developmental conditions and reproductive health management.
HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for Q95.3 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Clearly document which sex chromosome and autosome are involved
- •Record associated clinical manifestations or abnormalities
Clinical Significance
This code represents balanced rearrangements involving both sex chromosomes and autosomes in individuals with abnormal phenotypes, indicating that despite balanced genetic material, the rearrangement disrupts normal gene function or regulation. These complex rearrangements often result in developmental abnormalities and reproductive issues requiring specialized medical care.
Documentation Requirements
- ✓Cytogenetic analysis showing balanced sex/autosomal rearrangement
- ✓Sex chromosomes and autosomes involved
- ✓Type of rearrangement documented
- ✓Clinical abnormalities in affected individual
- ✓Reproductive history or fertility issues
- ✓Associated developmental delays
- ✓Breakpoint analysis if available
- ✓Genetic counseling documentation