H43.13
BillableVitreous hemorrhage, bilateral
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is H43.13 an HCC code?
Yes. H43.13 maps to Proliferative Diabetic Retinopathy and Vitreous Hemorrhage under the CMS-HCC V28 risk adjustment model (and Proliferative Diabetic Retinopathy and Vitreous Hemorrhage 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 H43.13
For H43.13 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 H43.13 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
H43.13 is the ICD-10-CM diagnosis code for vitreous hemorrhage, bilateral. Bleeding inside the clear gel of both eyes, causing vision loss or floaters in both eyes. H43.13 sits in the ICD-10-CM chapter for diseases of the eye and adnexa (h00-h59), within the section covering disorders of vitreous body and globe (h43-h44).
Under the CMS-HCC V28 risk adjustment model, H43.13 maps to Proliferative Diabetic Retinopathy and Vitreous Hemorrhage (HCC 298) with a community, non-dual, aged base RAF weight of 0.209. The V24 model used during the PY2024–PY2025 transition mapped H43.13 the same way and at the same RAF weight. 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 only when vitreous hemorrhage is documented in both eyes. Because H43.13 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 H43.13 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Use only when vitreous hemorrhage is documented in both eyes
- •Bilateral presentation warrants investigation for systemic causes such as diabetes, bleeding disorders, or bilateral retinal pathology
Clinical Significance
Vitreous hemorrhage represents bleeding into the vitreous cavity of the eye, which can significantly impair vision and may indicate serious underlying conditions such as proliferative diabetic retinopathy, retinal tear or detachment, or posterior vitreous detachment. This diagnosis carries notable risk adjustment weight, reflecting the clinical complexity and resource utilization associated with evaluation and management.
Documentation Requirements
- ✓Laterality clearly specified as bilateral
- ✓Clinical documentation of vitreous hemorrhage confirmed by dilated fundus examination or B-scan ultrasonography
- ✓Documented underlying etiology when identified (diabetic retinopathy, retinal tear, trauma, etc.)
- ✓Visual acuity assessment
- ✓Duration and onset of symptoms (acute vs. chronic/recurrent)
- ✓Treatment plan (observation, intravitreal injection, vitrectomy, laser treatment)
- ✓If diabetic, document the relationship to diabetic retinopathy with appropriate combination code
Commonly Confused Codes
- •H35.60-H35.63 — Retinal hemorrhage (bleeding within or on the retinal surface, not in the vitreous cavity)
- •H44.811-H44.819 — Hemophthalmos (blood in the anterior chamber, not vitreous; though terminology overlaps)
- •H31.301-H31.309 — Choroidal hemorrhage (bleeding in the choroid, not vitreous)
- •E11.3511-E11.3593 — Type 2 diabetes with proliferative diabetic retinopathy with vitreous hemorrhage (use combination code when diabetes is the cause)
- •H43.311-H43.313 — Vitreous membranes and strands (sequela of old hemorrhage, not active bleeding)