H04.313 ICD-10-CM Code: Phlegmonous dacryocystitis of bilateral lacrimal passages
H04.313 is not a CMS-HCC payment code. MEAT criteria · RAF Calculator · HCC Buddy coding tools
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FY 2026 Apr update / Diseases of the eye and adnexa (H00-H59) / Disorders of eyelid, lacrimal system and orbit (H00-H05)
H04.313
Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidancePhlegmonous dacryocystitis of bilateral lacrimal passages
A severe spreading infection affecting the tear drainage system on both sides of the face, with inflammation and pus formation in both lacrimal sacs.
CMS-HCC V28
N/A—
Not mapped
CMS-HCC V24
HistoricalHistorical
Not used for CY2026 payment
ACA/HHS
N/A—
Not mapped
ESRD/PACE
N/A—
Not mapped
RXHCC
N/A—
Not mapped
Code Book Path
Inclusion Terms
OfficialICD-10-CM does not list inclusion terms for H04.313 in this effective period.
Excludes 2
OfficialICD-10-CM does not list Excludes 2 notes for H04.313 in this effective period.
Related Child Codes
Includes
OfficialICD-10-CM does not list Includes notes for H04.313 in this effective period.
Excludes 1
OfficialICD-10-CM does not list Excludes 1 notes for H04.313 in this effective period.
Code First
OfficialICD-10-CM does not list Code First sequencing instructions for H04.313 in this effective period.
Use Additional
OfficialICD-10-CM does not list Use Additional Code instructions for H04.313 in this effective period.
Code Also
OfficialICD-10-CM does not list Code Also instructions for H04.313 in this effective period.
Buddy Documentation Tip
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 H04.313 an HCC code?
No. H04.313 is a billable ICD-10-CM code with no mapping under the CMS-HCC V28 or V24 community payment models, and none under the ESRD, Part D RxHCC, or HHS-HCC models.
- Code
- H04.313
- Description
- Phlegmonous dacryocystitis of bilateral lacrimal passages
- HCC (V28)
- No CMS-HCC V28 mapping
- RAF reference coefficient
- —
- Billable
- Yes
- Payment year
- 2026
Coder workflow notes
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This code does not map to an HCC category in any model (V28, V24, ESRD, RxHCC).
What This Code Means
H04.313 is the ICD-10-CM diagnosis code for phlegmonous dacryocystitis of bilateral lacrimal passages. A severe spreading infection affecting the tear drainage system on both sides of the face, with inflammation and pus formation in both lacrimal sacs. H04.313 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).
H04.313 is a billable ICD-10-CM code, but the current payload does not show a mapping under the CMS-HCC V28 or V24 community payment models, 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.
Bilateral coding requires documentation confirming involvement of both eyes; do not assume bilateral without explicit statement.
HCC Buddy maintains structured V28 and V24 mapping, source-labeled coefficient references, and MEAT documentation criteria for H04.313 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Bilateral coding requires documentation confirming involvement of both eyes; do not assume bilateral without explicit statement
- •Phlegmonous presentation suggests more aggressive infection requiring careful clinical correlation