H36.811
BillableNonproliferative sickle-cell retinopathy, right eye
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is H36.811 an HCC code?
Yes. H36.811 maps to Sickle Cell Disorders and Thalassemia under the CMS-HCC V28 risk adjustment model (and Severe Hematological Disorders under V24).
HCC Category Mapping
RAF weights shown are the community, non-dual, aged base weights from the CMS risk adjustment model file. Actual per-patient RAF contribution depends on member segment, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains in use during the transition and for historical data.
MEAT Criteria for H36.811
For H36.811 to count as a valid HCC diagnosis in a given encounter, the provider's documentation must show MEAT: Monitor, Evaluate, Assess, or Treat. A diagnosis from a prior year does not carry forward automatically — it has to be re-documented and supported each calendar year.
- MMonitor: signs, symptoms, disease progression, or lab trending documented in the note
- EEvaluate: test results, medication response, or physical findings reviewed by the provider
- AAssess: explicit mention in the assessment or plan with acknowledgment of status
- TTreat: medication, referral, procedure, therapy, or counseling tied to the diagnosis
Only one of M/E/A/T is required to support the code, but the documentation must be specific enough to show that the provider actually addressed H36.811 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
H36.811 is the ICD-10-CM diagnosis code for nonproliferative sickle-cell retinopathy, right eye. Early-stage eye blood vessel damage caused by sickle cell disease in the right eye, without abnormal new blood vessel growth. H36.811 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).
Under the CMS-HCC V28 risk adjustment model, H36.811 maps to Sickle Cell Disorders and Thalassemia (HCC 108) with a community, non-dual, aged base RAF weight of 0.607. Under the older CMS-HCC V24 model, H36.811 maps to Severe Hematological Disorders (HCC 46) with a community, non-dual, aged base RAF weight of 0.666. V28 is the CMS-HCC risk adjustment model that reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition.
This code requires documentation of sickle-cell disease as the underlying cause. Because H36.811 maps to a payment HCC, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's Medicare Advantage risk adjustment score. When documentation is ambiguous, coders should issue a provider query rather than assume the highest-specificity variant.
HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for H36.811 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
Clinical Significance
Nonproliferative sickle-cell retinopathy of the right eye represents early retinal vascular changes caused by sickle cell disease, including salmon-patch hemorrhages, iridescent spots, and black sunbursts. While less severe than the proliferative form, it indicates ongoing retinal vascular compromise and requires regular ophthalmic surveillance to detect progression. This code captures both the underlying hematological severity and the end-organ retinal damage.
Documentation Requirements
- ✓Dilated fundoscopic examination documenting nonproliferative retinal changes in the right eye
- ✓Specific retinal findings (salmon-patch hemorrhages, iridescent spots, black sunbursts, venous tortuosity)
- ✓Documentation of underlying sickle cell disease type (HbSS, HbSC, HbS-beta thalassemia)
- ✓Staging of retinopathy severity and absence of neovascularization
- ✓Follow-up surveillance plan with recommended interval for repeat examination
Commonly Confused Codes
- •H36.821 — Proliferative sickle-cell retinopathy, right eye: more severe form with neovascularization present
- •H36.812 — Nonproliferative sickle-cell retinopathy, left eye: contralateral side
- •H35.029 — Exudative retinopathy, unspecified eye: different pathology not related to sickle cell
- •E11.3211 — Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy, right eye: diabetic cause, not sickle cell