Question 1

What is ICD-10 code H02.004?

Accepted Answer

H02.004 is the ICD-10-CM diagnosis code for unspecified entropion of left upper eyelid. The upper eyelid of the left eye turns inward toward the eye surface, but the specific cause is not identified. H02.004 sits in the ICD-10-CM chapter for diseases of the eye and adnexa (h00-h59), within the section covering disorders of eyelid, lacrimal system and orbit (h00-h05).

H02.004 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 specifies the left upper eyelid, so ensure documentation confirms left eye and upper lid involvement.

Question 2

Is H02.004 an HCC code?

Accepted Answer

No. H02.004 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 H02.004 billable?

Accepted Answer

Yes. H02.004 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. H02.004 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 H02.004?

Accepted Answer

H02.004 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 H02.004 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 H02.004?

Accepted Answer

This code specifies the left upper eyelid, so ensure documentation confirms left eye and upper lid involvement Differentiate from H02.005 which codes the lower eyelid

H02.004

Is H02.004 an HCC code?

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Open H02.004 in the Interactive Encoder