Question 1

What is ICD-10 code H61.109?

Accepted Answer

H61.109 is the ICD-10-CM diagnosis code for unspecified noninfective disorders of pinna, unspecified ear. A general disorder affecting the outer ear (pinna) that is not caused by infection, when the specific ear is not documented. H61.109 sits in the ICD-10-CM chapter for diseases of the ear and mastoid process (h60-h95), within the section covering diseases of external ear (h60-h62).

H61.109 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.

Use only when laterality cannot be determined; request clarification from provider for proper code assignment.

Question 2

Is H61.109 an HCC code?

Accepted Answer

No. H61.109 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 H61.109 billable?

Accepted Answer

Yes. H61.109 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. H61.109 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 H61.109?

Accepted Answer

H61.109 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 H61.109 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 H61.109?

Accepted Answer

Use only when laterality cannot be determined; request clarification from provider for proper code assignment This is the least specific code in this category; bilateral or unilateral codes are preferred

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H61.109

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H61.109 ICD-10-CM Code: Unspecified noninfective disorders of pinna, unspecified ear

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H61.109

Is H61.109 an HCC code?

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What This Code Means

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Child Codes

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Work H61.109 in HCC Buddy