Question 1

What is ICD-10 code H16.241?

Accepted Answer

H16.241 is the ICD-10-CM diagnosis code for ophthalmia nodosa, right eye. Ophthalmia nodosa is an eye inflammation caused by contact with caterpillar hairs or similar irritating substances, resulting in small nodules on the eye surface. This code specifically refers to this condition affecting the right eye. H16.241 sits in the ICD-10-CM chapter for diseases of the eye and adnexa (h00-h59), within the section covering disorders of sclera, cornea, iris and ciliary body (h15-h22).

H16.241 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 in the medical record before assigning this code; if bilateral, assign separate codes for each eye (H16.241 for right, H16.242 for left).

Question 2

Is H16.241 an HCC code?

Accepted Answer

No. H16.241 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 H16.241 billable?

Accepted Answer

Yes. H16.241 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. H16.241 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 H16.241?

Accepted Answer

H16.241 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 H16.241 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 H16.241?

Accepted Answer

Verify laterality is documented in the medical record before assigning this code; if bilateral, assign separate codes for each eye (H16.241 for right, H16.242 for left) Document the causative agent (caterpillar hairs, plant material, etc.) in the medical record when possible, as this may support medical necessity and help with clinical correlation

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H16.241

Is H16.241 an HCC code?

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