H04.612
BillableLacrimal fistula left lacrimal passage
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is H04.612 an HCC code?
No. H04.612 is a billable ICD-10-CM code but does not map to any HCC category in V28, V24, ESRD, or RxHCC.
This code does not map to an HCC category in any model (V28, V24, ESRD, RxHCC).
What This Code Means
H04.612 is the ICD-10-CM diagnosis code for lacrimal fistula left lacrimal passage. An abnormal opening or tunnel in the tear drainage system on the left side that allows tears or fluid to leak through an unintended pathway. H04.612 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).
H04.612 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 documentation specifies left-sided location; if bilateral, use H04.613 instead.
HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for H04.612 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Ensure documentation specifies left-sided location; if bilateral, use H04.613 instead
- •Document the location of the fistula opening (skin, nasal cavity, etc.) if available