H36.821
BillableProliferative sickle-cell retinopathy, right eye
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is H36.821 an HCC code?
No. H36.821 is a billable ICD-10-CM code but does not map to any HCC category in V28, V24, ESRD, or RxHCC.
This code does not map to an HCC category in any model (V28, V24, ESRD, RxHCC).
What This Code Means
H36.821 is the ICD-10-CM diagnosis code for proliferative sickle-cell retinopathy, right eye. Abnormal new blood vessel growth in the back of the right eye due to sickle cell disease, representing advanced retinopathy. H36.821 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).
H36.821 is a billable ICD-10-CM code but does not map to a payment HCC under the CMS-HCC V28, V24, ESRD, or RxHCC risk adjustment models. It can be reported on Medicare Advantage encounter data submissions but it does not contribute to a beneficiary's RAF score and therefore does not affect risk-adjusted payments to the plan.
H36.821 does not map to any HCC in V28, V24, ESRD, or RxHCC models. Despite being clinically more severe than nonproliferative sickle-cell retinopathy, the proliferative form currently lacks an HCC mapping. The risk adjustment value for sickle cell disease patients is captured primarily through the underlying hemoglobinopathy codes (D57 series), which carry significant HCC value.
HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for H36.821 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Proliferative indicates more advanced disease than nonproliferative; ensure documentation supports this distinction
- •Right eye specification requires clear documentation; do not assume laterality
Clinical Significance
Proliferative sickle-cell retinopathy of the right eye represents the advanced stage of sickle cell retinal disease characterized by neovascularization (abnormal new blood vessel growth), which can lead to vitreous hemorrhage, retinal detachment, and vision loss. This is a more sight-threatening condition than the nonproliferative form and typically requires active treatment including laser photocoagulation or anti-VEGF therapy.
Documentation Requirements
- ✓Dilated fundoscopic examination documenting neovascularization (sea fan formations) in the right eye
- ✓Fluorescein angiography results when performed showing areas of nonperfusion and neovascularization
- ✓Staging using the Goldberg classification (stages I-V)
- ✓Documentation of underlying sickle cell disease type
- ✓Treatment plan including laser photocoagulation, anti-VEGF injections, or observation with close monitoring
Commonly Confused Codes
- •H36.811 — Nonproliferative sickle-cell retinopathy, right eye: earlier stage without neovascularization
- •H36.822 — Proliferative sickle-cell retinopathy, left eye: contralateral side
- •E11.3511 — Type 2 diabetes with proliferative diabetic retinopathy, right eye: diabetic cause, not sickle cell
- •H35.171 — Retrolental fibroplasia, right eye: different etiology (premature infant oxygen exposure)