Question 1

What is ICD-10 code H57.059?

Accepted Answer

H57.059 is the ICD-10-CM diagnosis code for tonic pupil, unspecified eye. A condition where a pupil becomes enlarged and responds slowly to light, but the specific eye affected is not documented. H57.059 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).

H57.059 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; attempt to obtain clarification on which eye is affected to assign the more specific code.

Question 2

Is H57.059 an HCC code?

Accepted Answer

No. H57.059 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 H57.059 billable?

Accepted Answer

Yes. H57.059 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. H57.059 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 H57.059?

Accepted Answer

H57.059 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 H57.059 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 H57.059?

Accepted Answer

This is a less specific code; attempt to obtain clarification on which eye is affected to assign the more specific code Use only when laterality cannot be determined from medical record documentation

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H57.059

Is H57.059 an HCC code?

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Open H57.059 in the Interactive Encoder

H57.059 ICD-10-CM Code: Tonic pupil, unspecified eye

HCC Buddy Code Card

H57.059

Is H57.059 an HCC code?

What This Code Means

Coding Tips

Child Codes

Code Hierarchy

Open H57.059 in the Interactive Encoder