H11.159 is not a CMS-HCC payment code. MEAT criteria · RAF Calculator · HCC Buddy coding tools

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Code lookupH11.159

Effective periodFY2026 Apr Update (Apr 1-Sep 30)

FY 2026 Apr update / Diseases of the eye and adnexa (H00-H59) / Disorders of conjunctiva (H10-H11)

H11.159

Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidance

Pinguecula, unspecified eye

A small, yellowish growth on the clear membrane of the eye when the specific eye affected is not documented or specified.

Overview Risk Models Code Book Documentation Audit Notes Edition comparison

CMS-HCC V28

N/A

—

Not risk-adjusted for this model/period.

Not mapped

CMS-HCC V24

Historical

Not used for standard CY2026 Medicare Advantage payment. Select a historical period to review V24.

Not used for CY2026 payment

ACA/HHS

N/A

—

Not risk-adjusted for this model/period.

Not mapped

ESRD/PACE

N/A

—

Not risk-adjusted for this model/period.

Not mapped

RXHCC

N/A

—

Not risk-adjusted for this model/period.

Not mapped

Code Book Path

Official

H11.1Conjunctival degenerations and deposits H11.15Pinguecula H11.159Pinguecula, unspecified eye

Inclusion Terms

Official

No inclusion terms are included in this display for H11.159. Check the code and parent instructions in the Code Book.

Excludes 2

Official

certain conditions originating in the perinatal period (P04-P96)Inherited from H00-H59, H11.1
certain infectious and parasitic diseases (A00-B99)Inherited from H00-H59, H11.1
complications of pregnancy, childbirth and the puerperium (O00-O9A)Inherited from H00-H59, H11.1
congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)Inherited from H00-H59, H11.1
diabetes mellitus related eye conditions (E09.3-, E10.3-, E11.3-, E13.3-)Inherited from H00-H59, H11.1
endocrine, nutritional and metabolic diseases (E00-E88)Inherited from H00-H59, H11.1
injury (trauma) of eye and orbit (S05.-)Inherited from H00-H59, H11.1
injury, poisoning and certain other consequences of external causes (S00-T88)Inherited from H00-H59, H11.1
neoplasms (C00-D49)Inherited from H00-H59, H11.1
symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)Inherited from H00-H59, H11.1
syphilis related eye disorders (A50.01, A50.3-, A51.43, A52.71)Inherited from H00-H59, H11.1
pseudopterygium (H11.81)Inherited from H00-H59, H11.1

Related Codes

Official

H11.151Pinguecula, right eye H11.152Pinguecula, left eye H11.153Pinguecula, bilateral

Includes

Official

No Includes notes are included in this display for H11.159. Check the code and parent instructions in the Code Book.

Excludes 1

Official

keratoconjunctivitis (H16.2-)Inherited from H11, H11.15
pingueculitis (H10.81-)Inherited from H11, H11.15

Code First

Official

No Code First sequencing instructions are included in this display for H11.159. Check the code and parent instructions in the Code Book.

Use Additional

Official

No Use Additional Code instructions are included in this display for H11.159. Check the code and parent instructions in the Code Book.

Code Also

Official

No Code Also instructions are included in this display for H11.159. Check the code and parent instructions in the Code Book.

Buddy Documentation Tip

HCC Buddy guidance

Use only when laterality cannot be determined; query provider for clarification when possible

This is a less specific code; attempt to obtain laterality information before finalizing the claim

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 H11.159 an HCC code?

No. H11.159 is a billable ICD-10-CM code with no mapping under the current CMS-HCC V28 community payment model, and none under the ESRD, Part D RxHCC, or HHS-HCC models.

Code: H11.159
Description: Pinguecula, unspecified eye
HCC (V28): No CMS-HCC V28 mapping
RAF reference coefficient: —
Billable: Yes
Payment year: 2026

Coder workflow notes

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What This Code Means

H11.159 is the ICD-10-CM diagnosis code for pinguecula, unspecified eye. A small, yellowish growth on the clear membrane of the eye when the specific eye affected is not documented or specified. H11.159 sits in the ICD-10-CM chapter for diseases of the eye and adnexa (h00-h59), within the section covering disorders of conjunctiva (h10-h11).

H11.159 is a billable ICD-10-CM code, but no current CMS-HCC V28 community payment mapping is shown, 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.

Use only when laterality cannot be determined; query provider for clarification when possible.

HCC Buddy maintains structured V28 and V24 mapping, source-labeled coefficient references, and MEAT documentation criteria for H11.159 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.

Coding Tips

•Use only when laterality cannot be determined; query provider for clarification when possible
•This is a less specific code; attempt to obtain laterality information before finalizing the claim