T86.811
BillableLung transplant failure
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is T86.811 an HCC code?
Yes. T86.811 maps to Lung Transplant Status/Complications under the CMS-HCC V28 risk adjustment model (and Major Organ Transplant or Replacement Status under V24).
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 T86.811
For T86.811 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 T86.811 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
T86.811 is the ICD-10-CM diagnosis code for lung transplant failure. The transplanted lung stops functioning properly or fails to work as expected after transplantation. T86.811 sits in the ICD-10-CM chapter for injury, poisoning and certain other consequences of external causes (s00-t88), within the section covering complications of surgical and medical care, not elsewhere classified (t80-t88).
Under the CMS-HCC V28 risk adjustment model, T86.811 maps to Lung Transplant Status/Complications (HCC 276) with a community, non-dual, aged base RAF weight of 0.193. Under the older CMS-HCC V24 model, T86.811 maps to Major Organ Transplant or Replacement Status (HCC 186) with a community, non-dual, aged base RAF weight of 0.910. 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.
Differentiate between primary graft failure (occurs immediately) and secondary graft failure (occurs later). Because T86.811 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 T86.811 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Differentiate between primary graft failure (occurs immediately) and secondary graft failure (occurs later)
- •Document the clinical evidence of lung failure such as decreased function, need for re-transplant, or mechanical support
Clinical Significance
Lung transplant failure indicates severe graft dysfunction regardless of cause, representing a life-threatening condition requiring intensive management and possible retransplantation consideration. This diagnosis carries significant mortality risk and healthcare resource utilization implications.
Documentation Requirements
- ✓Documentation of previous lung transplant with procedure date
- ✓Evidence of graft failure (pulmonary function tests, imaging studies, biopsy)
- ✓Clinical manifestations of failure (severe dyspnea, hypoxemia, respiratory failure)
- ✓Exclusion or identification of reversible causes
- ✓Arterial blood gas results demonstrating respiratory compromise
- ✓Chest imaging showing graft dysfunction
- ✓Provider assessment confirming transplant failure
- ✓Current management plan including consideration for retransplantation
Commonly Confused Codes
- •T86.810 — lung transplant rejection (failure vs specific rejection mechanism)
- •T86.812 — lung transplant infection (failure vs infectious complication)
- •J96.90 — respiratory failure unspecified (transplant-related vs non-transplant respiratory failure)
- •Z94.2 — lung transplant status (failure vs stable transplant status)
- •T86.818 — other lung transplant complications (failure vs other specific complications)