H36.813
BillableNonproliferative sickle-cell retinopathy, bilateral
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is H36.813 an HCC code?
Yes. H36.813 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 H36.813
For H36.813to 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 H36.813 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
H36.813 is the ICD-10-CM diagnosis code for nonproliferative sickle-cell retinopathy, bilateral. Damage to the blood vessels in the back of both eyes caused by sickle cell disease, without abnormal new blood vessel growth. H36.813 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, H36.813 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, H36.813 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 bilateral specification; verify documentation confirms both eyes are affected. Because H36.813 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 H36.813 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •This code requires bilateral specification; verify documentation confirms both eyes are affected
- •Nonproliferative indicates early-stage retinopathy; confirm proliferative changes are not present before coding
Clinical Significance
Nonproliferative sickle-cell retinopathy, bilateral indicates that both eyes demonstrate early-stage sickle cell retinal changes, reflecting more widespread vascular compromise. Bilateral involvement may indicate more severe systemic sickle cell disease and carries a higher risk of progression to proliferative disease in one or both eyes. This necessitates close bilateral ophthalmologic surveillance.
Documentation Requirements
- ✓Bilateral dilated fundoscopic examination documenting nonproliferative changes in both eyes
- ✓Comparison of findings between right and left eyes to assess symmetry of disease
- ✓Documentation of underlying sickle cell disease type and severity
- ✓Staging of retinopathy in each eye individually
- ✓Bilateral surveillance plan with follow-up interval
Commonly Confused Codes
- •H36.811/H36.812 — Nonproliferative sickle-cell retinopathy, right/left eye: use when only one eye is affected
- •H36.823 — Proliferative sickle-cell retinopathy, bilateral: both eyes with neovascularization (more severe)
- •H36.819 — Nonproliferative sickle-cell retinopathy, unspecified eye: less specific, use only when laterality truly unknown
- •E11.3393 — Type 2 diabetes with nonproliferative diabetic retinopathy, bilateral: diabetic cause, not sickle cell