H04.001 is not a CMS-HCC payment code. MEAT criteria · RAF Calculator · HCC Buddy coding tools

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Code lookupH04.001

Effective periodFY2026 Apr Update (Apr 1-Sep 30)

FY 2026 Apr update / Diseases of the eye and adnexa (H00-H59) / Disorders of eyelid, lacrimal system and orbit (H00-H05)

H04.001

Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidance

Unspecified dacryoadenitis, right lacrimal gland

Inflammation of the tear gland (lacrimal gland) on the right side of the eye, causing swelling, pain, or excessive tearing.

Overview Risk Models Code Book Documentation Audit Notes Edition comparison

CMS-HCC V28

N/A

—

Not risk-adjusted for this model/period.

Not mapped

CMS-HCC V24

Historical

Not used for standard CY2026 Medicare Advantage payment. Select a historical period to review V24.

Not used for CY2026 payment

ACA/HHS

N/A

—

Not risk-adjusted for this model/period.

Not mapped

ESRD/PACE

N/A

—

Not risk-adjusted for this model/period.

Not mapped

RXHCC

N/A

—

Not risk-adjusted for this model/period.

Not mapped

Code Book Path

Official

H04.0Dacryoadenitis H04.00Unspecified dacryoadenitis H04.001Unspecified dacryoadenitis, right lacrimal gland

Inclusion Terms

Official

No inclusion terms are included in this display for H04.001. Check the code and parent instructions in the Code Book.

Excludes 2

Official

certain conditions originating in the perinatal period (P04-P96)Inherited from H00-H59, H00-H05
certain infectious and parasitic diseases (A00-B99)Inherited from H00-H59, H00-H05
complications of pregnancy, childbirth and the puerperium (O00-O9A)Inherited from H00-H59, H00-H05
congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)Inherited from H00-H59, H00-H05
diabetes mellitus related eye conditions (E09.3-, E10.3-, E11.3-, E13.3-)Inherited from H00-H59, H00-H05
endocrine, nutritional and metabolic diseases (E00-E88)Inherited from H00-H59, H00-H05
injury (trauma) of eye and orbit (S05.-)Inherited from H00-H59, H00-H05
injury, poisoning and certain other consequences of external causes (S00-T88)Inherited from H00-H59, H00-H05
neoplasms (C00-D49)Inherited from H00-H59, H00-H05
symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)Inherited from H00-H59, H00-H05
syphilis related eye disorders (A50.01, A50.3-, A51.43, A52.71)Inherited from H00-H59, H00-H05
open wound of eyelid (S01.1-)Inherited from H00-H59, H00-H05
superficial injury of eyelid (S00.1-, S00.2-)Inherited from H00-H59, H00-H05

Related Codes

Official

H04.002Unspecified dacryoadenitis, left lacrimal gland H04.003Unspecified dacryoadenitis, bilateral lacrimal glands H04.009Unspecified dacryoadenitis, unspecified lacrimal gland

Includes

Official

No Includes notes are included in this display for H04.001. Check the code and parent instructions in the Code Book.

Excludes 1

Official

congenital malformations of lacrimal system (Q10.4-Q10.6)Inherited from H04

Code First

Official

No Code First sequencing instructions are included in this display for H04.001. Check the code and parent instructions in the Code Book.

Use Additional

Official

No Use Additional Code instructions are included in this display for H04.001. Check the code and parent instructions in the Code Book.

Code Also

Official

No Code Also instructions are included in this display for H04.001. Check the code and parent instructions in the Code Book.

Buddy Documentation Tip

HCC Buddy guidance

Specify laterality (right) to differentiate from left-sided involvement

Document whether this is acute or chronic inflammation to guide treatment decisions

Current with CMS: FY2026 ICD-10-CM Apr 1 update (effective Apr 1 – Sep 30, 2026) · CMS-HCC V28, 100% phased in for payment year 2026. FY2027 code set already staged for October 1, 2026. How HCC Buddy stays current →

Is H04.001 an HCC code?

No. H04.001 is a billable ICD-10-CM code with no mapping under the current CMS-HCC V28 community payment model, and none under the ESRD, Part D RxHCC, or HHS-HCC models.

Code: H04.001
Description: Unspecified dacryoadenitis, right lacrimal gland
HCC (V28): No CMS-HCC V28 mapping
RAF reference coefficient: —
Billable: Yes
Payment year: 2026

Coder workflow notes

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What This Code Means

H04.001 is the ICD-10-CM diagnosis code for unspecified dacryoadenitis, right lacrimal gland. Inflammation of the tear gland (lacrimal gland) on the right side of the eye, causing swelling, pain, or excessive tearing. H04.001 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).

H04.001 is a billable ICD-10-CM code, but no current CMS-HCC V28 community payment mapping is shown, and none under the ESRD, Part D RxHCC, or HHS-HCC models. Do not assign risk adjustment value from this page when no source-backed mapping is shown; verify the applicable model and payment year.

Specify laterality (right) to differentiate from left-sided involvement.

HCC Buddy maintains structured V28 and V24 mapping, source-labeled coefficient references, and MEAT documentation criteria for H04.001 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.

Coding Tips

•Specify laterality (right) to differentiate from left-sided involvement
•Document whether this is acute or chronic inflammation to guide treatment decisions