Question 1

What is ICD-10 code H31.323?

Accepted Answer

H31.323 is the ICD-10-CM diagnosis code for choroidal rupture, bilateral. A choroidal rupture is a break or tear in the choroid layer of the eye (the blood vessel layer beneath the retina). This code indicates that this condition is present in both eyes. H31.323 sits in the ICD-10-CM chapter for diseases of the eye and adnexa (h00-h59), within the section covering disorders of choroid and retina (h30-h36).

H31.323 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 documentation specifies bilateral involvement before assigning this code; unilateral ruptures require different codes (H31.321 for right eye, H31.322 for left eye).

Question 2

Is H31.323 an HCC code?

Accepted Answer

No. H31.323 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 H31.323 billable?

Accepted Answer

Yes. H31.323 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. H31.323 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 H31.323?

Accepted Answer

H31.323 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 H31.323 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 H31.323?

Accepted Answer

Verify documentation specifies bilateral involvement before assigning this code; unilateral ruptures require different codes (H31.321 for right eye, H31.322 for left eye) Choroidal ruptures are typically traumatic in origin, so review the medical record for associated eye injury codes and ensure proper sequencing with the external cause code

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H31.323

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H31.323 ICD-10-CM Code: Choroidal rupture, bilateral

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H31.323

Is H31.323 an HCC code?

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