Question 1

What is ICD-10 code H21.43?

Accepted Answer

H21.43 is the ICD-10-CM diagnosis code for pupillary membranes, bilateral. This condition involves abnormal tissue membranes covering the pupil (the dark center of the eye) in both eyes. These membranes can affect vision by blocking or distorting light entry into the eye. H21.43 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).

H21.43 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 that the condition is documented as bilateral (affecting both eyes) before assigning this code; if only one eye is affected, use H21.41 or H21.42 instead.

Question 2

Is H21.43 an HCC code?

Accepted Answer

No. H21.43 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 H21.43 billable?

Accepted Answer

Yes. H21.43 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. H21.43 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 H21.43?

Accepted Answer

H21.43 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 H21.43 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 H21.43?

Accepted Answer

Verify that the condition is documented as bilateral (affecting both eyes) before assigning this code; if only one eye is affected, use H21.41 or H21.42 instead This code is typically used for congenital pupillary membranes or acquired membranes from inflammation or surgery; ensure the underlying cause is documented separately if relevant to treatment

HCC Buddy Code Card

H21.43

Is H21.43 an HCC code?

What This Code Means

Coding Tips

Child Codes

Code Hierarchy

Open H21.43 in the Interactive Encoder

H21.43 ICD-10-CM Code: Pupillary membranes, bilateral

HCC Buddy Code Card

H21.43

Is H21.43 an HCC code?

What This Code Means

Coding Tips

Child Codes

Code Hierarchy

Open H21.43 in the Interactive Encoder