2026 ICD-10-CM Diagnosis Code J95.04Tracheo-esophageal fistula following tracheostomy
ICD-10-CM Codes›J00–J99›J95›J95
- Billable — Valid for Submission
- CC — Complication or Comorbidity
- Risk Adjusts — HCC 211
- Not Chronic
J95.04 is a billable ICD-10-CM diagnosis code for tracheo-esophageal fistula following tracheostomy. It is valid on HIPAA claims for fiscal year 2026 (October 1, 2025 through September 30, 2026) and groups to MS-DRG 11 through 13, 205 through 206. As a secondary diagnosis, it counts as a complication or comorbidity (CC) and moves an inpatient stay to a higher severity level within its MS-DRG family. It does not count, however, when the principal diagnosis is one of 12 closely related codes. Coders also document this condition as postoperative fistula. In AHRQ's Clinical Classifications Software (CCSR), this diagnosis falls under Postprocedural or postoperative respiratory system complication.
For Medicare Advantage risk adjustment, J95.04 maps to CMS-HCC Category 211 (Respirator Dependence/Tracheostomy Status/Complications) under the V28 model, adding a risk factor of about 0.879 for a community, non-dual, aged beneficiary in payment year 2026.
Code Identity
Code Classification
Medicare Risk Adjustment (HCC)Billing
J95.04 maps to a payment category in the CMS-HCC model used to risk-adjust Medicare Advantage payments. Weights are the published community factors for payment year 2026.
Source: CMS Payment Year 2026 risk adjustment mappings and model software. Weights are relative factors, not dollar amounts; a beneficiary's total RAF also includes demographics and interactions. Browse all CMS-HCC categories.
Approximate SynonymsGuidance
Alternate terms and clinical phrases that map to this code.
- Postoperative fistula
- Tracheoesophageal fistula
- Tracheoesophageal fistula following tracheostomy
- Tracheostomy complication
Index to Diseases and InjuriesGuidance
Alphabetical index entries that point to this code.
Clinical ClassificationClinical
AHRQ’s CCSR groups this code into broader clinical categories.
Clinical InformationClinical
Tracheoesophageal Fistula
abnormal passage between the esophagus and the trachea, acquired or congenital, often associated with esophageal atresia.
Patient EducationClinical
Fistulas
A fistula is an abnormal connection between two parts inside of the body. Fistulas may develop between different organs, such as between the esophagus and the windpipe or the bowel and the vagina. They can also develop between two blood vessels, such as between an artery and a vein or between two arteries.
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Convert J95.04 to ICD-9-CMHistory
The closest ICD-9-CM equivalents under the General Equivalence Mappings.
Code HistoryHistory
Questions About J95.04Overview
What is the ICD-10 code for tracheo-esophageal fistula following tracheostomy?
The ICD-10-CM code for tracheo-esophageal fistula following tracheostomy is J95.04 (sometimes written as J9504). It is billable on HIPAA-covered claims from October 1, 2025 through September 30, 2026.
Is J95.04 (Tracheostomy complications) a billable code?
Yes. This is a billable ICD-10-CM code, specific enough to report tracheo-esophageal fistula following tracheostomy on HIPAA-covered claims from October 1, 2025 through September 30, 2026.
What MS-DRG does J95.04 group to?
When tracheo-esophageal fistula following tracheostomy is the principal diagnosis on an inpatient stay, it groups to MS-DRG 11, 12, 13, 205, 206, with relative weights from 0.9411 to 5.4541 depending on complications. Higher weights mean higher Medicare reimbursement.
Is J95.04 a CC or MCC?
CMS lists J95.04 as a CC (complication or comorbidity) for FY 2026. Reported as a secondary diagnosis, it moves the inpatient stay to a higher-weighted DRG within its severity family. It does not count when the principal diagnosis is one of the 12 closely related codes in its exclusion list.
What is the ICD-9 equivalent of J95.04?
Under the General Equivalence Mappings, tracheo-esophageal fistula following tracheostomy converts to ICD-9-CM 519.09 (tracheostomy comp NEC). The mapping is approximate, so confirm the match fits the documentation.
What HCC is J95.04?
J95.04 (tracheo-esophageal fistula following tracheostomy) maps to CMS-HCC Category 211 (Respirator Dependence/Tracheostomy Status/Complications), commonly written as HCC 211, in the CMS-HCC V28 model used for Medicare Advantage risk adjustment in payment year 2026. It mapped to HCC 82 under the retired V24 model. It also maps in the PACE (CMS-HCC V22), ESRD (V21), and ESRD (V24) models. It does not map to any RxHCC in the Part D prescription drug model.
Does J95.04 risk-adjust for Medicare Advantage payment?
Yes. When documented and reported on a Medicare Advantage encounter, J95.04 adds a risk adjustment factor of about 0.879 to the beneficiary's RAF score for a community, non-dual, aged enrollee (published V28 weights range from 0.590 to 1.981 depending on the payment segment). HCC 211 sits at the top of its hierarchy, so no other condition category supersedes it. See the full factor table on the HCC 211 category page.
