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.

What is the V28 vs V24 difference for H36.819?

CMS phased in the V28 risk adjustment model over payment years 2024 (33%), 2025 (67%), and 2026 (100%), replacing V24. V28 consolidates HCC categories, removes some lower-acuity conditions, and recalibrates RAF weights across the entire model. For H36.819, V28 maps to Sickle Cell Disorders and Thalassemia at RAF 0.607 while V24 mapped to Severe Hematological Disorders at RAF 0.666. Both models can still appear in legacy data and in payer-specific lookback periods.

What should coders know when reporting H36.819?

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 Because H36.819 maps to a payment HCC, the documentation must also satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's risk adjustment score.

H36.819 ICD-10 Code: Nonproliferative sickle-cell

ICD-10-CM Code View

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Digital ICD-10 code-book layout with official code detail, always-visible risk models, Code Trumping, and Buddy coding guidance.

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 and Tha...

RAF 0.607

CMS-HCC V24

Mapped

HCC 46

Severe Hematological Disorders

RAF 0.666

ACA/HHS

Not risk-adjusted for this model/period.

RAF 0

ESRD/PACE

Mapped

HCC 46

Severe Hematological Disorders

RAF 0.0

RXHCC

Not risk-adjusted for this model/period.

RAF 0

Code Trumping

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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

Last updated: FY2026 ICD-10-CM Apr update, Apr 1, 2026 through Sep 30, 2026. CMS-HCC V28 is 100% phased in for payment year 2026.

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

V28HCC 108, Sickle Cell Disorders and Thalassemia

0.607

V24HCC 46, Severe Hematological Disorders

0.666

ESRDHCC 46, Severe Hematological Disorders

0.000

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