Question 1

What is ICD-10 code H05.811?

Accepted Answer

H05.811 is the ICD-10-CM diagnosis code for cyst of right orbit. A fluid-filled sac or pocket that develops in the tissue surrounding the right eye (the orbit). This cyst is typically benign and may or may not cause symptoms depending on its size and location. H05.811 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).

H05.811 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.

Verify laterality is documented as 'right' in the medical record before assigning this code; use H05.812 for left orbit or H05.813 for bilateral cases.

Question 2

Is H05.811 an HCC code?

Accepted Answer

No. H05.811 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 H05.811 billable?

Accepted Answer

Yes. H05.811 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. H05.811 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 H05.811?

Accepted Answer

H05.811 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 H05.811 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 H05.811?

Accepted Answer

Verify laterality is documented as 'right' in the medical record before assigning this code; use H05.812 for left orbit or H05.813 for bilateral cases Confirm the cyst is of the orbit itself and not of the eyelid (which would use a different code from the H02 category); review imaging reports or operative notes for anatomical confirmation

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H05.811

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