Question 1

What is ICD-10 code H35.152?

Accepted Answer

H35.152 is the ICD-10-CM diagnosis code for retinopathy of prematurity, stage 4, left eye. An eye condition in premature infants where abnormal blood vessels develop in the retina, classified as stage 4 severity (severe with partial retinal detachment) in the left eye. H35.152 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).

H35.152 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.

Stage 4 ROP involves partial retinal detachment and carries high risk of permanent vision loss or blindness.

Question 2

Is H35.152 an HCC code?

Accepted Answer

No. H35.152 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 H35.152 billable?

Accepted Answer

Yes. H35.152 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. H35.152 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

Which HCC does H35.152 map to under V28?

Accepted Answer

H35.152 does not map to a CMS-HCC V28 payment category. Check the current CMS-HCC V28 model file for payment year 2026 rather than an older V24 tip sheet.

Question 5

What does H35.152 pay in RAF?

Accepted Answer

H35.152 has no separately stated V28 community RAF weight. If it is not a V28 payment HCC, it adds nothing to a community RAF score.

Question 6

What is the V28 vs V24 difference for H35.152?

Accepted Answer

H35.152 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 community model rewards H35.152 with a risk adjustment factor, it contributes zero to a Medicare Advantage beneficiary's V28/V24 community RAF score in either version. Coders should check whether provider documentation supports a more specific child code that does map to a community payment HCC.

Question 7

What documentation supports H35.152?

Accepted Answer

Stage 4 ROP involves partial retinal detachment and carries high risk of permanent vision loss or blindness Stage 4 and 5 ROP are considered severe; document any surgical interventions (vitrectomy, scleral buckle) with separate procedure codes H35.152 is not a CMS-HCC payment code, so MEAT is not the payment hook. Documentation still has to support the diagnosis if you report it.

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H35.152

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H35.152 ICD-10-CM Code: Retinopathy of prematurity, stage 4, left eye

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H35.152

Is H35.152 an HCC code?

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