H36.812
BillableNonproliferative sickle-cell retinopathy, left eye
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is H36.812 an HCC code?
Yes. H36.812 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 H36.812
For H36.812to 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 H36.812 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
H36.812 is the ICD-10-CM diagnosis code for nonproliferative sickle-cell retinopathy, left eye. Early-stage eye blood vessel damage caused by sickle cell disease in the left eye, without abnormal new blood vessel growth. H36.812 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, H36.812 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, H36.812 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 H36.812 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 H36.812 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 left eye indicates early-stage retinal vascular changes from sickle cell disease in the left eye. The clinical significance, monitoring requirements, and management approach are identical to right eye involvement. Accurate laterality coding is essential for tracking disease progression in each eye independently.
Documentation Requirements
- ✓Dilated fundoscopic examination documenting nonproliferative changes specifically in the left eye
- ✓Description of retinal findings (salmon-patch hemorrhages, iridescent spots, black sunbursts)
- ✓Documentation of underlying sickle cell disease genotype
- ✓Comparison with prior examinations to assess for progression
- ✓Surveillance plan and referral to retinal specialist if needed
Commonly Confused Codes
- •H36.822 — Proliferative sickle-cell retinopathy, left eye: more advanced stage with neovascularization
- •H36.811 — Nonproliferative sickle-cell retinopathy, right eye: same condition, contralateral side
- •H36.813 — Nonproliferative sickle-cell retinopathy, bilateral: use when both eyes are affected
- •H35.039 — Exudative retinopathy, unspecified: non-sickle-cell retinal pathology