Question 1

What is ICD-10 code H26.109?

Accepted Answer

H26.109 is the ICD-10-CM diagnosis code for unspecified traumatic cataract, unspecified eye. A clouding of the lens caused by an eye injury, but the specific eye affected is not documented. H26.109 sits in the ICD-10-CM chapter for diseases of the eye and adnexa (h00-h59), within the section covering disorders of lens (h25-h28).

H26.109 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.

This code should be avoided when possible; always attempt to determine which eye is affected from the medical record.

Question 2

Is H26.109 an HCC code?

Accepted Answer

No. H26.109 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 H26.109 billable?

Accepted Answer

Yes. H26.109 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. H26.109 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 H26.109?

Accepted Answer

H26.109 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 H26.109 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 H26.109?

Accepted Answer

This code should be avoided when possible; always attempt to determine which eye is affected from the medical record Query the provider if laterality is not specified to allow for more precise coding

HCC Buddy Code Card

H26.109

Is H26.109 an HCC code?

Get the V28 RAF + MEAT cheat sheet

What This Code Means

Coding Tips

Child Codes

Code Hierarchy

Work H26.109 in HCC Buddy

H26.109 ICD-10-CM Code: Unspecified traumatic cataract, unspecified eye

HCC Buddy Code Card

H26.109

Is H26.109 an HCC code?

Get the V28 RAF + MEAT cheat sheet

What This Code Means

Coding Tips

Child Codes

Code Hierarchy

Work H26.109 in HCC Buddy