Question 1

What is ICD-10 code H57.051?

Accepted Answer

H57.051 is the ICD-10-CM diagnosis code for tonic pupil, right eye. A condition affecting the right eye where the pupil becomes abnormally dilated and responds slowly to light changes, often due to nerve damage. H57.051 sits in the ICD-10-CM chapter for diseases of the eye and adnexa (h00-h59), within the section covering other disorders of eye and adnexa (h55-h57).

H57.051 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 code is specific to the right eye; use H57.052 for left eye involvement.

Question 2

Is H57.051 an HCC code?

Accepted Answer

No. H57.051 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 H57.051 billable?

Accepted Answer

Yes. H57.051 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. H57.051 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 H57.051?

Accepted Answer

H57.051 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 H57.051 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 H57.051?

Accepted Answer

This code is specific to the right eye; use H57.052 for left eye involvement Document the degree of pupil dilation and any associated vision or accommodation problems

HCC Buddy Code Card

H57.051

Is H57.051 an HCC code?

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Open H57.051 in the Interactive Encoder

H57.051 ICD-10-CM Code: Tonic pupil, right eye

HCC Buddy Code Card

H57.051

Is H57.051 an HCC code?

What This Code Means

Coding Tips

Child Codes

Code Hierarchy

Open H57.051 in the Interactive Encoder