Question 1

What is ICD-10 code H16.249?

Accepted Answer

H16.249 is the ICD-10-CM diagnosis code for ophthalmia nodosa, unspecified eye. A type of eye inflammation with small nodular lesions on the conjunctiva affecting an unspecified eye, usually caused by irritation from foreign material or allergic reaction. H16.249 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).

H16.249 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.

Use this code only when the specific eye affected is not documented; query provider for laterality if possible.

Question 2

Is H16.249 an HCC code?

Accepted Answer

No. H16.249 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 H16.249 billable?

Accepted Answer

Yes. H16.249 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. H16.249 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 H16.249?

Accepted Answer

H16.249 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 H16.249 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 H16.249?

Accepted Answer

Use this code only when the specific eye affected is not documented; query provider for laterality if possible Document the suspected cause of the nodular lesions to guide treatment decisions

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H16.249

Is H16.249 an HCC code?

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H16.249 ICD-10-CM Code: Ophthalmia nodosa, unspecified eye

HCC Buddy Code Card

H16.249

Is H16.249 an HCC code?

What This Code Means

Coding Tips

Child Codes

Code Hierarchy

Open H16.249 in the Interactive Encoder