Question 1

What is ICD-10 code Y95?

Accepted Answer

Y95 is the ICD-10-CM diagnosis code for nosocomial condition. A condition that develops as a result of being in a hospital or healthcare facility, such as a hospital-acquired infection or complication from medical care. This code indicates the condition was not present before admission. Y95 sits in the ICD-10-CM chapter for external causes of morbidity (v00-y99), within the section covering supplementary factors related to causes of morbidity classified elsewhere (y90-y99).

Y95 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.

Document the specific nosocomial condition with an additional diagnosis code (e.g., C. difficile infection, MRSA).

Question 2

Is Y95 an HCC code?

Accepted Answer

No. Y95 is a billable ICD-10-CM code but does not map to any payment HCC category under the CMS-HCC V28, V24, ESRD, or RxHCC risk adjustment models. It can still be reported on Medicare Advantage encounter data submissions, but it does not contribute to the beneficiary's Risk Adjustment Factor (RAF) score and therefore does not affect the risk-adjusted capitation payment to the plan. V28 reached 100% phase-in for payment year 2026.

Question 3

Is Y95 billable?

Accepted Answer

Yes. Y95 is a billable ICD-10-CM code that can be reported on professional and institutional claims as a primary or secondary diagnosis when the provider documentation supports the specific condition described. Billable codes in ICD-10-CM are coded to the highest level of specificity available for the documented diagnosis. Y95 is current for fiscal year 2026 and remains in the active CMS ICD-10-CM code set published by the National Center for Health Statistics.

Question 4

What is the V28 vs V24 difference for Y95?

Accepted Answer

Y95 does not map to a payment HCC under either the CMS-HCC V28 risk adjustment model or the older V24 model. V28 reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition. Because neither model rewards Y95 with a risk adjustment factor, it contributes zero to a Medicare Advantage beneficiary's RAF score in either version. Coders should check whether provider documentation supports a more specific child code that does map to a payment HCC.

Question 5

What should coders know when reporting Y95?

Accepted Answer

Document the specific nosocomial condition with an additional diagnosis code (e.g., C. difficile infection, MRSA) Ensure the condition developed during the current hospitalization and was not present on admission

HCC Buddy Code Card

Y95

Is Y95 an HCC code?

What This Code Means

Coding Tips

Code Hierarchy

Open Y95 in the Interactive Encoder

Y95 ICD-10-CM Code: Nosocomial condition

HCC Buddy Code Card

Y95

Is Y95 an HCC code?

What This Code Means

Coding Tips

Code Hierarchy

Open Y95 in the Interactive Encoder