Question 1

What is ICD-10 code H53.412?

Accepted Answer

H53.412 is the ICD-10-CM diagnosis code for Scotoma involving central area, left eye. It belongs to the ICD-10-CM chapter for diseases of the eye and adnexa (h00-h59). H53.412 is a billable code, meaning it can be reported on a claim as a primary or secondary diagnosis when supported by documentation. H53.412 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.

Question 2

Is H53.412 an HCC code?

Accepted Answer

No. H53.412 is a billable ICD-10-CM code but does not map to any payment HCC category under the CMS-HCC V28, V24, ESRD, or RxHCC risk adjustment models. It can still be reported on Medicare Advantage encounter data submissions, but it does not contribute to the beneficiary's Risk Adjustment Factor (RAF) score and therefore does not affect the risk-adjusted capitation payment to the plan. V28 reached 100% phase-in for payment year 2026.

Question 3

Is H53.412 billable?

Accepted Answer

Yes. H53.412 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. H53.412 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.

Question 4

What is the V28 vs V24 difference for H53.412?

Accepted Answer

H53.412 does not map to a payment HCC under either the CMS-HCC V28 risk adjustment model or the older V24 model. V28 reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition. Because neither model rewards H53.412 with a risk adjustment factor, it contributes zero to a Medicare Advantage beneficiary's RAF score in either version. Coders should check whether provider documentation supports a more specific child code that does map to a payment HCC.

Question 5

What should coders know when reporting H53.412?

Accepted Answer

Verify laterality is documented as left eye only; if bilateral, code both H53.411 (right eye) and H53.412 (left eye) separately Investigate and document the underlying cause (such as macular degeneration, diabetic retinopathy, or optic nerve disease) as this may require additional coding and affects treatment decisions

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H53.412

Is H53.412 an HCC code?

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