Question 1

What is ICD-10 code H16.261?

Accepted Answer

H16.261 is the ICD-10-CM diagnosis code for vernal keratoconjunctivitis, with limbar and corneal involvement, right eye. A seasonal allergic inflammation of the cornea and conjunctiva with involvement of the limbus (border of the cornea) and corneal surface, affecting the right eye. It typically occurs in warm weather. H16.261 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).

H16.261 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.

Vernal keratoconjunctivitis is more common in children and young adults in warm climates; document seasonal pattern if present.

Question 2

Is H16.261 an HCC code?

Accepted Answer

No. H16.261 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 H16.261 billable?

Accepted Answer

Yes. H16.261 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. H16.261 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 H16.261?

Accepted Answer

H16.261 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 H16.261 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 H16.261?

Accepted Answer

Vernal keratoconjunctivitis is more common in children and young adults in warm climates; document seasonal pattern if present Ensure right eye laterality is clearly documented; this code specifies limbal and corneal involvement

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H16.261

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H16.261 ICD-10-CM Code: Vernal keratoconjunctivitis, with limbar and corneal involvement, right eye

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H16.261

Is H16.261 an HCC code?

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