H36.823 ICD-10-CM Code: Proliferative sickle-cell retinopathy, bilateral
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FY 2026 Apr update / Diseases of the eye and adnexa (H00-H59) / Disorders of choroid and retina (H30-H36)
H36.823
Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidanceProliferative sickle-cell retinopathy, bilateral
Abnormal new blood vessel growth in the back of both eyes due to sickle cell disease, representing advanced retinopathy affecting both sides.
Buddy Insight
Proliferative sickle-cell retinopathy, bilateral indicates advanced sickle cell retinal disease with neovascularization in both eyes, representing the most severe retinal manifestation of sickle cell disease.
CMS-HCC V28
00
RAF 0
CMS-HCC V24
00
RAF 0
ACA/HHS
00
RAF 0
ESRD/PACE
00
RAF 0
RXHCC
00
RAF 0
Code Trumping
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Code Book Path
Inclusion Terms
OfficialICD-10-CM does not list inclusion terms for H36.823 in this effective period.
Excludes 2
OfficialICD-10-CM does not list Excludes 2 notes for H36.823 in this effective period.
Related Child Codes
Includes
OfficialICD-10-CM does not list Includes notes for H36.823 in this effective period.
Excludes 1
OfficialICD-10-CM does not list Excludes 1 notes for H36.823 in this effective period.
Code First
OfficialICD-10-CM does not list Code First sequencing instructions for H36.823 in this effective period.
Use Additional
OfficialICD-10-CM does not list Use Additional Code instructions for H36.823 in this effective period.
Code Also
OfficialICD-10-CM does not list Code Also instructions for H36.823 in this effective period.
Buddy Documentation Tip
MEAT Support
Audit Caution
Common Mistakes
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 H36.823 an HCC code?
No. H36.823 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
H36.823 is the ICD-10-CM diagnosis code for proliferative sickle-cell retinopathy, bilateral. Abnormal new blood vessel growth in the back of both eyes due to sickle cell disease, representing advanced retinopathy affecting both sides. H36.823 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).
H36.823 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.
H36.823 does not map to any HCC in V28, V24, ESRD, or RxHCC models. This is the most severe form of sickle cell retinopathy, yet it carries no independent HCC value. Risk adjustment relies entirely on the underlying sickle cell disease codes (D57 series). Bilateral proliferative disease is a clinical indicator of severe systemic sickle cell disease that should prompt review of the underlying hemoglobinopathy coding.
HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for H36.823 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Bilateral specification requires documentation confirming both eyes have proliferative changes
- •This advanced form warrants close ophthalmologic monitoring and may require intervention
Clinical Significance
Proliferative sickle-cell retinopathy, bilateral indicates advanced sickle cell retinal disease with neovascularization in both eyes, representing the most severe retinal manifestation of sickle cell disease. Bilateral proliferative disease carries a significant risk of bilateral vision loss and reflects severe underlying systemic disease. These patients require aggressive bilateral retinal management and close systemic monitoring.
Documentation Requirements
- ✓Bilateral dilated fundoscopic examination documenting neovascularization in both eyes
- ✓Individual staging (Goldberg classification) for each eye
- ✓Fluorescein angiography of both eyes documenting areas of nonperfusion and neovascularization
- ✓Documentation of sickle cell disease type and systemic disease severity
- ✓Bilateral treatment plan and coordination with hematology
Commonly Confused Codes
- •H36.813 — Nonproliferative sickle-cell retinopathy, bilateral: earlier stage without neovascularization in either eye
- •H36.821/H36.822 — Proliferative sickle-cell retinopathy, right/left eye: use when only one eye has proliferative disease
- •H36.829 — Proliferative sickle-cell retinopathy, unspecified eye: less specific, use only when laterality unknown
- •E11.3593 — Type 2 diabetes with proliferative diabetic retinopathy, bilateral: diabetic etiology, not sickle cell