Question 1

What is ICD-10 code H04.031?

Accepted Answer

H04.031 is the ICD-10-CM diagnosis code for chronic enlargement of right lacrimal gland. Persistent enlargement of the tear-producing gland in the right eye. H04.031 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).

H04.031 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 specifically indicates enlargement rather than inflammation; ensure documentation supports this distinction.

Question 2

Is H04.031 an HCC code?

Accepted Answer

No. H04.031 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 H04.031 billable?

Accepted Answer

Yes. H04.031 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. H04.031 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 H04.031?

Accepted Answer

H04.031 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 H04.031 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 H04.031?

Accepted Answer

This code specifically indicates enlargement rather than inflammation; ensure documentation supports this distinction Use H04.032 for left eye or H04.033 for bilateral enlargement

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H04.031

Is H04.031 an HCC code?

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Open H04.031 in the Interactive Encoder

H04.031 ICD-10-CM Code: Chronic enlargement of right lacrimal gland

HCC Buddy Code Card

H04.031

Is H04.031 an HCC code?

What This Code Means

Coding Tips

Child Codes

Code Hierarchy

Open H04.031 in the Interactive Encoder