H36.819
BillableNonproliferative sickle-cell retinopathy, unspecified eye
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is H36.819 an HCC code?
Yes. H36.819 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 H36.819
For H36.819to 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.
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 and Thalassemia (HCC 108) with a community, non-dual, aged base RAF weight of 0.607. Under the older CMS-HCC V24 model, H36.819 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.
Use this code only when laterality cannot be determined from documentation. Because H36.819 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 H36.819 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