What is ICD-10 code H36.819?

H36.819 is the ICD-10-CM diagnosis code for Nonproliferative sickle-cell retinopathy, unspecified eye. Damage to the blood vessels in the back of the eye caused by sickle cell disease without abnormal new blood vessel growth, when the specific eye is not documented. H36.819 is a billable code, meaning it can be reported on a claim as a primary or secondary diagnosis when supported by documentation. H36.819 is part of the FY2026 ICD-10-CM code set published by the CMS National Center for Health Statistics and used on Medicare, Medicaid, and commercial claims in the United States.

Yes. H36.819 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. H36.819 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.

Which HCC does H36.819 map to under V28?

H36.819 maps to CMS-HCC V28 HCC 108 (Sickle Cell Disorders, Except Sickle Cell Anemia (Hb-SS) and Thalassemia Beta Zero; Beta Thalassemia Major). The category numbers, labels, and conditions come from the CMS-HCC V28 model file for payment year 2026.

2026 ICD-10-CM H36.819: Nonproliferative

H36.819 maps to CMS-HCC V28 108. A source-labeled RAF reference is available. Documentation must support MEAT. MEAT criteria · RAF Calculator · HCC coding software

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Code lookupH36.819Effective periodFY2026 Apr Update (Apr 1-Sep 30)

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

H36.819

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

Nonproliferative sickle-cell retinopathy, unspecified eye

Damage to the blood vessels in the back of the eye caused by sickle cell disease without abnormal new blood vessel growth, when the specific eye is not documented.

Buddy Insight

Nonproliferative sickle-cell retinopathy, unspecified eye is used when the laterality of the sickle cell retinopathy is not documented.

CMS-HCC V28

Mapped

HCC 108

Sickle Cell Disorders, Except...

Code-level coefficient reference

CMS-HCC V24

Historical

Not used for standard CY2026 Medicare Advantage payment. Select a historical period to review V24.

Not used for CY2026 payment

ACA/HHS

Mapped

HCC 071

HHS-HCC 071 adult, RAF varies...

Code-level coefficient reference

ESRD/PACE

Mapped

HCC 46

Severe Hematological Disorders

Code-level coefficient reference

RXHCC

N/A

—

Not risk-adjusted for this model/period.

Not mapped

Code Book Path

Official

H36.8Other retinal disorders in diseases classified elsewhere

H36.81Nonproliferative sickle-cell retinopathy

H36.819Nonproliferative sickle-cell retinopathy, unspecified eye

Inclusion Terms

Official

ICD-10-CM does not list inclusion terms for H36.819 in this effective period.

Excludes 2

Official

ICD-10-CM does not list Excludes 2 notes for H36.819 in this effective period.

Related Child Codes

Official

H36.811Nonproliferative sickle-cell retinopathy, right eye

H36.812Nonproliferative sickle-cell retinopathy, left eye

H36.813Nonproliferative sickle-cell retinopathy, bilateral

Includes

Official

ICD-10-CM does not list Includes notes for H36.819 in this effective period.

Excludes 1

Official

ICD-10-CM does not list Excludes 1 notes for H36.819 in this effective period.

Code First

Official

ICD-10-CM does not list Code First sequencing instructions for H36.819 in this effective period.

Use Additional

Official

ICD-10-CM does not list Use Additional Code instructions for H36.819 in this effective period.

Code Also

Official

ICD-10-CM does not list Code Also instructions for H36.819 in this effective period.

Buddy Documentation Tip

HCC Buddy guidance

Documentation of nonproliferative sickle cell retinopathy without laterality specification

Confirmation of sickle cell disease diagnosis

Clinical rationale for why laterality cannot be determined from available records

Referral or query to the examining ophthalmologist for laterality determination

MEAT Support

HCC Buddy guidance

Documentation of nonproliferative sickle cell retinopathy without laterality specification

Confirmation of sickle cell disease diagnosis

Clinical rationale for why laterality cannot be determined from available records

Referral or query to the examining ophthalmologist for laterality determination

Audit Caution

HCC Buddy guidance

Using this code when laterality information exists in ophthalmology notes

Not querying the ophthalmologist for laterality documentation

Confusing this with the proliferative form, which requires different management

Not coding the underlying sickle cell disease separately

Common Mistakes

HCC Buddy guidance

H36.811-H36.813 — Laterality-specific nonproliferative sickle-cell retinopathy: always preferred when laterality is documented

H36.829 — Proliferative sickle-cell retinopathy, unspecified eye: more severe stage, also unspecified laterality

H35.9 — Unspecified retinal disorder: overly nonspecific, does not capture sickle cell etiology

D57.1 — Sickle-cell disease without crisis: underlying condition, not the retinal manifestation

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 H36.819 an HCC code?

Yes. H36.819 (Nonproliferative sickle-cell retinopathy, unspecified 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: H36.819 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: H36.819
Description: Nonproliferative sickle-cell retinopathy, unspecified 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 H36.819 in the Code Book — tabular path, V28 RAF reference, and MEAT checklist →

MEAT Criteria for H36.819

For H36.819 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 H36.819 during that encounter, not just copy-forwarded from a problem list.

Coder workflow notes

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What This Code Means

H36.819 is the ICD-10-CM diagnosis code for nonproliferative sickle-cell retinopathy, unspecified eye. Damage to the blood vessels in the back of the eye caused by sickle cell disease without abnormal new blood vessel growth, when the specific eye is not documented. H36.819 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, H36.819 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 H36.819; use the applicable model and payment year when reviewing the V28 mapping. 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. 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.

Use this code only when laterality cannot be determined from documentation. Because H36.819 maps to an HCC category, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) before the diagnosis is used for risk adjustment. 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 H36.819 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.

Coding Tips

•Use this code only when laterality cannot be determined from documentation
•Query provider if eye-specific information is available to allow for more specific coding

Clinical Significance

Nonproliferative sickle-cell retinopathy, unspecified eye is used when the laterality of the sickle cell retinopathy is not documented. While it captures the same HCC value as laterality-specific codes, this represents a documentation quality issue that should be addressed through provider query. Most ophthalmologic examinations document laterality, so this code should be rarely needed.

Documentation Requirements

✓Documentation of nonproliferative sickle cell retinopathy without laterality specification
✓Confirmation of sickle cell disease diagnosis
✓Clinical rationale for why laterality cannot be determined from available records
✓Referral or query to the examining ophthalmologist for laterality determination
✓Treatment and surveillance plan

Commonly Confused Codes

•H36.811-H36.813: Laterality-specific nonproliferative sickle-cell retinopathy: always preferred when laterality is documented
•H36.829: Proliferative sickle-cell retinopathy, unspecified eye: more severe stage, also unspecified laterality
•H35.9: Unspecified retinal disorder: overly nonspecific, does not capture sickle cell etiology
•D57.1: Sickle-cell disease without crisis: underlying condition, not the retinal manifestation