Question 1

What is ICD-10 code H02.225?

Accepted Answer

H02.225 is the ICD-10-CM diagnosis code for mechanical lagophthalmos left lower eyelid. Inability of the left lower eyelid to close completely due to mechanical causes such as muscle weakness or nerve damage. H02.225 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).

H02.225 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.

Ensure you are coding the left eye, not the right eye, as this distinction is critical for accurate documentation.

Question 2

Is H02.225 an HCC code?

Accepted Answer

No. H02.225 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 H02.225 billable?

Accepted Answer

Yes. H02.225 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. H02.225 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 H02.225?

Accepted Answer

H02.225 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 H02.225 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 H02.225?

Accepted Answer

Ensure you are coding the left eye, not the right eye, as this distinction is critical for accurate documentation Mechanical causes may include seventh cranial nerve involvement or eyelid surgery complications

HCC Buddy Code Card

H02.225

Is H02.225 an HCC code?

What This Code Means

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Child Codes

Code Hierarchy

Open H02.225 in the Interactive Encoder

H02.225 ICD-10-CM Code: Mechanical lagophthalmos left lower eyelid

HCC Buddy Code Card

H02.225

Is H02.225 an HCC code?

What This Code Means

Coding Tips

Child Codes

Code Hierarchy

Open H02.225 in the Interactive Encoder