Question 1

What is ICD-10 code H26.113?

Accepted Answer

H26.113 is the ICD-10-CM diagnosis code for localized traumatic opacities, bilateral. This code describes clouding or haziness of the lens in both eyes caused by trauma or injury. The opacity (cloudiness) is limited to a specific area of the lens rather than affecting the entire lens. H26.113 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).

H26.113 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 documentation specifies bilateral involvement (both eyes) before assigning this code; if only one eye is affected, use the unilateral code H26.111 instead.

Question 2

Is H26.113 an HCC code?

Accepted Answer

No. H26.113 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 H26.113 billable?

Accepted Answer

Yes. H26.113 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. H26.113 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 H26.113?

Accepted Answer

H26.113 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 H26.113 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 H26.113?

Accepted Answer

Verify that the documentation specifies bilateral involvement (both eyes) before assigning this code; if only one eye is affected, use the unilateral code H26.111 instead Ensure the opacities are documented as traumatic in origin and localized to a specific region; if the trauma is recent and acute, consider also coding the external cause code (W-codes) to indicate how the injury occurred

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H26.113

Is H26.113 an HCC code?

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Open H26.113 in the Interactive Encoder

H26.113 ICD-10-CM Code: Localized traumatic opacities, bilateral

HCC Buddy Code Card

H26.113

Is H26.113 an HCC code?

What This Code Means

Coding Tips

Child Codes

Code Hierarchy

Open H26.113 in the Interactive Encoder