Question 1

What is ICD-10 code H35.172?

Accepted Answer

H35.172 is the ICD-10-CM diagnosis code for retrolental fibroplasia, left eye. Retrolental fibroplasia of the left eye, a condition where scar tissue forms behind the lens in premature infants, often resulting from severe retinopathy of prematurity. H35.172 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).

H35.172 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.

Retrolental fibroplasia is another term for advanced ROP with fibrotic tissue formation; ensure left eye is documented.

Question 2

Is H35.172 an HCC code?

Accepted Answer

No. H35.172 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 H35.172 billable?

Accepted Answer

Yes. H35.172 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. H35.172 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 H35.172?

Accepted Answer

H35.172 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 H35.172 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 H35.172?

Accepted Answer

Retrolental fibroplasia is another term for advanced ROP with fibrotic tissue formation; ensure left eye is documented This condition typically follows untreated or severe ROP progression

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H35.172

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H35.172 ICD-10-CM Code: Retrolental fibroplasia, left eye

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H35.172

Is H35.172 an HCC code?

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