Question 1

What is ICD-10 code H54.3?

Accepted Answer

H54.3 is the ICD-10-CM diagnosis code for unqualified visual loss, both eyes. Vision loss in both eyes that cannot be more specifically classified or categorized. The exact severity or type of vision loss is not documented. H54.3 sits in the ICD-10-CM chapter for diseases of the eye and adnexa (h00-h59), within the section covering visual disturbances and blindness (h53-h54).

H54.3 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.

This is a less specific code; use only when the documentation does not provide enough detail to assign a more specific bilateral vision loss code.

Question 2

Is H54.3 an HCC code?

Accepted Answer

No. H54.3 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 H54.3 billable?

Accepted Answer

Yes. H54.3 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. H54.3 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 H54.3?

Accepted Answer

H54.3 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 H54.3 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 H54.3?

Accepted Answer

This is a less specific code; use only when the documentation does not provide enough detail to assign a more specific bilateral vision loss code. Query the provider for more specific information about visual acuity in each eye to allow assignment of a more precise code.

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H54.3

Is H54.3 an HCC code?

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H54.3 ICD-10-CM Code: Unqualified visual loss, both eyes

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H54.3

Is H54.3 an HCC code?

What This Code Means

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Child Codes

Code Hierarchy

Open H54.3 in the Interactive Encoder