Question 1

What is ICD-10 code H04.611?

Accepted Answer

H04.611 is the ICD-10-CM diagnosis code for lacrimal fistula right lacrimal passage. An abnormal opening or tunnel in the tear drainage system on the right side that allows tears or fluid to leak through an unintended pathway. H04.611 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).

H04.611 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.

Confirm the fistula is in the lacrimal passage (not elsewhere) and document right-sided location.

Question 2

Is H04.611 an HCC code?

Accepted Answer

No. H04.611 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 H04.611 billable?

Accepted Answer

Yes. H04.611 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. H04.611 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 H04.611?

Accepted Answer

H04.611 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 H04.611 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 H04.611?

Accepted Answer

Confirm the fistula is in the lacrimal passage (not elsewhere) and document right-sided location Note whether the fistula is congenital or acquired, as this distinction may be clinically relevant

H04.611

Is H04.611 an HCC code?

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