Question 1

What is ICD-10 code Q13.5?

Accepted Answer

Q13.5 is the ICD-10-CM diagnosis code for Blue sclera. A congenital condition where the sclera (the white part of the eye) has an abnormally blue or gray appearance due to thinness or structural changes. Q13.5 is a billable code, meaning it can be reported on a claim as a primary or secondary diagnosis when supported by documentation. Q13.5 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 Q13.5 an HCC code?

Accepted Answer

No. Q13.5 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 Q13.5 billable?

Accepted Answer

Yes. Q13.5 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. Q13.5 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

Which HCC does Q13.5 map to under V28?

Accepted Answer

Q13.5 does not map to a CMS-HCC V28 payment category. Check the current CMS-HCC V28 model file for payment year 2026 rather than an older V24 tip sheet.

Question 5

What does Q13.5 pay in RAF?

Accepted Answer

Q13.5 has no separately stated V28 community RAF weight. If it is not a V28 payment HCC, it adds nothing to a community RAF score.

Question 6

What is the V28 vs V24 difference for Q13.5?

Accepted Answer

Q13.5 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 community model rewards Q13.5 with a risk adjustment factor, it contributes zero to a Medicare Advantage beneficiary's V28/V24 community RAF score in either version. Coders should check whether provider documentation supports a more specific child code that does map to a community payment HCC.

Question 7

What documentation supports Q13.5?

Accepted Answer

Blue sclera can be associated with osteogenesis imperfecta; document any systemic findings Specify laterality and note any progressive changes or associated ocular complications Q13.5 is not a CMS-HCC payment code, so MEAT is not the payment hook. Documentation still has to support the diagnosis if you report it.

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Q13.5 ICD-10-CM Code: Blue sclera

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Q13.5

Is Q13.5 an HCC code?

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