Question 1

What is ICD-10 code H16.111?

Accepted Answer

H16.111 is the ICD-10-CM diagnosis code for Macular keratitis, right eye. It belongs to the ICD-10-CM chapter for diseases of the eye and adnexa (h00-h59). H16.111 is a billable code, meaning it can be reported on a claim as a primary or secondary diagnosis when supported by documentation. H16.111 is part of the FY2026 ICD-10-CM code set published by the CMS National Center for Health Statistics and used on Medicare, Medicaid, and commercial claims in the United States.

Question 2

Is H16.111 an HCC code?

Accepted Answer

No. H16.111 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 H16.111 billable?

Accepted Answer

Yes. H16.111 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. H16.111 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 H16.111?

Accepted Answer

H16.111 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 H16.111 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 H16.111?

Accepted Answer

Verify laterality is documented in the medical record - this code specifically indicates the right eye, so ensure the provider has specified which eye is affected Macular keratitis may be associated with underlying conditions (such as infections, autoimmune diseases, or trauma) - review documentation for any additional diagnoses that should be coded separately

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H16.111

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H16.111 ICD-10-CM Code: Macular keratitis, right eye

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H16.111

Is H16.111 an HCC code?

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What This Code Means

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