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H36.811 ICD-10-CM Code: Nonproliferative sickle-cell retinopathy, right eye

H36.811 maps to CMS-HCC V28 108. A source-labeled RAF reference is available. Confirm the documented diagnosis and applicable coding requirements. MEAT criteria · RAF Calculator · free HCC coding tools

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Code lookupH36.811

FY 2026 Apr update / Diseases of the eye and adnexa (H00-H59) / Disorders of choroid and retina (H30-H36)

H36.811

Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidance

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.

Buddy the Bee presenting code insight

Buddy Insight

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.

OverviewRisk ModelsCode BookDocumentationAuditNotesEdition comparison

CMS-HCC V28

HCC 108

Coefficient HCC 108: 0.146 (Community Non-Dual Aged (CNA))

CMS-HCC V24

Historical

Historical

Not used for CY2026 payment

ACA/HHS

HCC 071

Code-level coefficient reference

ESRD/PACE

HCC 46

Code-level coefficient reference

RXHCC

N/A

—

Not mapped

Code Book Path

Official
H36.8Other retinal disorders in diseases classified elsewhereH36.81Nonproliferative sickle-cell retinopathyH36.811Nonproliferative sickle-cell retinopathy, right eye

Inclusion Terms

Official

No inclusion terms are included in this display for H36.811. Check the code and parent instructions in the Code Book.

Excludes 2

Official
  • certain conditions originating in the perinatal period (P04-P96)Inherited from H00-H59
  • certain infectious and parasitic diseases (A00-B99)Inherited from H00-H59
  • complications of pregnancy, childbirth and the puerperium (O00-O9A)Inherited from H00-H59
  • congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)Inherited from H00-H59
  • diabetes mellitus related eye conditions (E09.3-, E10.3-, E11.3-, E13.3-)Inherited from H00-H59
  • endocrine, nutritional and metabolic diseases (E00-E88)Inherited from H00-H59
  • injury (trauma) of eye and orbit (S05.-)Inherited from H00-H59
  • injury, poisoning and certain other consequences of external causes (S00-T88)Inherited from H00-H59
  • neoplasms (C00-D49)Inherited from H00-H59
  • symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)Inherited from H00-H59
  • syphilis related eye disorders (A50.01, A50.3-, A51.43, A52.71)Inherited from H00-H59

Related Codes

Official
H36.812Nonproliferative sickle-cell retinopathy, left eyeH36.813Nonproliferative sickle-cell retinopathy, bilateralH36.819Nonproliferative sickle-cell retinopathy, unspecified eye

Includes

Official

No Includes notes are included in this display for H36.811. Check the code and parent instructions in the Code Book.

Excludes 1

Official
  • arteriosclerotic retinopathy (H35.0-)Inherited from H36
  • diabetic retinopathy (E08.3-, E09.3-, E10.3-, E11.3-, E13.3-)Inherited from H36

Code First

Official
  • underlying disease, such as:Inherited from H36
  • lipid storage disorders (E75.-)Inherited from H36
  • sickle-cell disorders (D57.-)Inherited from H36

Use Additional

Official

No Use Additional Code instructions are included in this display for H36.811. Check the code and parent instructions in the Code Book.

Code Also

Official

No Code Also instructions are included in this display for H36.811. Check the code and parent instructions in the Code Book.

Buddy Documentation Tip

HCC Buddy guidance
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

MEAT Support

HCC Buddy guidance
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

Audit Caution

HCC Buddy guidance
Confusing nonproliferative with proliferative sickle-cell retinopathy — the presence of neovascularization is the distinguishing factor
Not coding the underlying sickle cell disease as a separate code
Using diabetic retinopathy codes when the retinopathy is caused by sickle cell disease
Not specifying laterality when the examination documents which eye is affected

Common Mistakes

HCC Buddy guidance
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

Current with CMS: FY2026 ICD-10-CM Apr 1 update (effective Apr 1 – Sep 30, 2026) · CMS-HCC V28, 100% phased in for payment year 2026. FY2027 code set already staged for October 1, 2026. How HCC Buddy stays current →

Is H36.811 an HCC code?

Yes. H36.811 (Nonproliferative sickle-cell retinopathy, right eye) maps to HCC 108, Sickle Cell Disorders, Except Sickle Cell Anemia (Hb-SS) and Thalassemia Beta Zero; Beta Thalassemia Major under the CMS-HCC V28 risk adjustment model, with a source-labeled community non-dual aged reference coefficient of 0.146. Source-labeled code-level coefficients are references, not member totals. Actual contribution depends on complete member context, hierarchy and cleanup rules, interactions, and model year. HCC Buddy's RAF Calculator supports CMS-HCC V28 PY2026 and shows no score unless every required source and calculation check passes. It is billable for payment year 2026.

Coder answer: H36.811 is billable and maps to V28 HCC 108, Sickle Cell Disorders, Except Sickle Cell Anemia (Hb-SS) and Thalassemia Beta Zero; Beta Thalassemia Major. Open it in the Code Book for the tabular path, RAF, and MEAT checklist.

Code
H36.811
Description
Nonproliferative sickle-cell retinopathy, right eye
HCC (V28)
HCC 108 — Sickle Cell Disorders, Except Sickle Cell Anemia (Hb-SS) and Thalassemia Beta Zero; Beta Thalassemia Major
RAF reference coefficient
0.146
Billable
Yes
Payment year
2026

HCC Category Mapping

V28HCC 108, Sickle Cell Disorders, Except Sickle Cell Anemia (Hb-SS) and Thalassemia Beta Zero; Beta Thalassemia Major
0.146
ESRDHCC 46, Severe Hematological Disorders
Not separately weighted

These are source-labeled model coefficients, not member totals. A category may still be removed by hierarchy or model cleanup rules. Weights are not directly comparable across models: CMS-HCC V28 and V24 use Community, Non-Dual, Aged; ESRD uses the dialysis continuing-enrollee model; RxHCC is the Part D continuing-enrollee, non-low-income, aged weight (a larger scale than CMS-HCC). ACA/HHS has no single weight — it varies by metal level. Actual per-patient RAF contribution depends on member context, hierarchy and cleanup rules, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains available for historical review.

Work H36.811 in the Code Book — tabular path, V28 RAF reference, and MEAT checklist →

MEAT review for H36.811

For H36.811, confirm that the documentation supports the diagnosis and meets the applicable coding, encounter, program and payer requirements. MEAT (Monitor, Evaluate, Assess, or Treat) is a review mnemonic, not a universal CMS coding rule.

  • 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

Coder workflow notes

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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, Except Sickle Cell Anemia (Hb-SS) and Thalassemia Beta Zero; Beta Thalassemia Major (HCC 108) with a source-labeled community, non-dual, aged reference coefficient of 0.146. No V24 mapping is shown for H36.811; use the applicable model and payment year when reviewing the V28 mapping. For CY2026 non-PACE Medicare Advantage, CMS uses 100% of the 2024 CMS-HCC model (V28). PACE uses a separate model blend. Source-labeled code-level coefficients are references, not member totals. Actual contribution depends on complete member context, hierarchy and cleanup rules, interactions, and model year. HCC Buddy's RAF Calculator supports CMS-HCC V28 PY2026 and shows no score unless every required source and calculation check passes.

This code requires documentation of sickle-cell disease as the underlying cause. For H36.811, confirm that the documentation supports the diagnosis and meets the applicable coding, encounter, program and payer requirements. MEAT (Monitor, Evaluate, Assess, or Treat) is a review mnemonic, not a universal CMS coding rule. 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, source-labeled coefficient references, 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

  • •This code requires documentation of sickle-cell disease as the underlying cause
  • •Verify laterality is documented as right eye; use H36.812 for left eye or H36.819 if unspecified

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

Child Codes

H36.811Nonproliferative sickle-cell retinopathy, right eye
HCC 108
H36.812Nonproliferative sickle-cell retinopathy, left eye
HCC 108
H36.813Nonproliferative sickle-cell retinopathy, bilateral
HCC 108
H36.819Nonproliferative sickle-cell retinopathy, unspecified eye
HCC 108

Code Hierarchy

└H36Retinal disorders in diseases classified elsewhere└H36.8Other retinal disorders in diseases classified elsewhere└H36.81Nonproliferative sickle-cell retinopathy└H36.811Nonproliferative sickle-cell retinopathy, right eye
└H36.811Nonproliferative sickle-cell retinopathy, right eye

H36.811 code history

Code setChange
FY2024 (effective Oct 1, 2023)Added to the code set

Source: official CMS ICD-10-CM order and addenda files, FY2016 through FY2027.

Also searched as

  • H36 811
  • H36811

For H36.811, confirm that the documentation supports the diagnosis and meets the applicable coding, encounter, program and payer requirements. MEAT (Monitor, Evaluate, Assess, or Treat) is a review mnemonic, not a universal CMS coding rule.

H36.811 maps to CMS-HCC V28 category 108, Sickle Cell Disorders, Except Sickle Cell Anemia (Hb-SS) and Thalassemia Beta Zero; Beta Thalassemia Major. See the ICD-10 to HCC mapping hub for how the V28 crosswalk works. The mapping identifies a payment HCC category for H36.811. Review its source-labeled HCC coefficient above, check the RAF Calculator with complete member context for CMS-HCC V28 PY2026, and confirm the documentation the chart needs before the code is submitted. HCC Buddy shows no RAF score unless every required source and calculation check passes.

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