2027 ICD-10-CM Diagnosis Code H36.813Nonproliferative sickle-cell retinopathy, bilateral

ICD-10-CM Codes›H00–H59›H30-H36›H36

ICD-10-CM H36.813
CMSSource: CMS FY 2027 ICD-10-CM dataset · Effective Oct 1, 2026 – Sep 30, 2027

H36.813 is a billable ICD-10-CM diagnosis code for nonproliferative sickle-cell retinopathy, bilateral. It is valid on HIPAA claims for fiscal year 2027 (October 1, 2026 through September 30, 2027) and groups to MS-DRG 124 through 125. The code is not accepted as a principal diagnosis by the Medicare Code Editor. Coders also document this condition as bilateral nonproliferative retinopathy due to sickle cell disease. In AHRQ's Clinical Classifications Software (CCSR), this diagnosis falls under Retinal and vitreous conditions and Sickle cell trait/anemia.

For Medicare Advantage risk adjustment, H36.813 maps to CMS-HCC Category 108 (Sickle Cell Disorders, Except Sickle Cell Anemia (Hb-SS) and Thalassemia Beta Zero; Beta Thalassemia Major) under the V28 model, adding a risk factor of about 0.146 for a community, non-dual, aged beneficiary in payment year 2027.

Code Identity

ICD-10-CM Code
H36.813
Billable Status
Yes — Valid for Submission
Code Describes
Nonproliferative sickle-cell retinopathy, bilateral
Short Description
Nonproliferative sickle-cell retinopathy, bilateral
Same as the full description in the CMS dataset.
Parent Code
H36.81
Nonproliferative sickle-cell retinopathy

Code Classification

ChapterH00–H59Diseases of the eye and adnexa
SectionH30-H36Disorders of choroid and retina
CategoryH36Retinal disorders in diseases classified elsewhere
This CodeH36.813Nonproliferative sickle-cell retinopathy, bilateral

Code EditsBilling

Medicare Code Editor checks that affect claim validity for H36.813.

Unacceptable principal diagnosis
There are selected codes that describe a circumstance which influences an individual's health status but not a current illness or injury, or codes that are not specific manifestations but may be due to an underlying cause. These codes are considered unacceptable as a principal diagnosis.

Medicare Risk Adjustment (HCC)Billing

H36.813 maps to a payment category in the CMS-HCC model used to risk-adjust Medicare Advantage payments. Weights are the published community factors for payment year 2027.

CMS-HCC V28 Category (Payment Model)
HCC 108— Sickle Cell Disorders, Except Sickle Cell Anemia (Hb-SS) and Thalassemia Beta Zero; Beta Thalassemia Major
Payment HCC · PY 2027 one of 39 ICD-10-CM codes in this category
Risk Adjustment Factor (RAF) Weight
+0.146
community, non-dual, aged · ranges 0.098–0.416 across segments
Hierarchy
Superseded by HCC 107
a more severe related category takes the payment when both are reported
Prior Model (CMS-HCC V24)
HCC 46
V24 retired V28 pays 100% of MA risk scores since PY 2026
Other CMS Models
PACE (CMS-HCC V22): HCC 46 · ESRD (V21): HCC 46 · ESRD (V24): HCC 46
ESRD V21 weights: 0.180 dialysis, 0.766–1.325 functioning graft · ESRD V24 weights: 0.223 dialysis, 0.748–4.064 functioning graft
Part D (RxHCC)
Not mapped
H36.813 does not risk-adjust in the RxHCC prescription drug model

Source: CMS Payment Year 2027 risk adjustment mappings and model software. Weights are relative factors, not dollar amounts; a beneficiary's total RAF also includes demographics and interactions. Browse all CMS-HCC categories.

Approximate SynonymsGuidance

Alternate terms and clinical phrases that map to this code.

  • Bilateral nonproliferative retinopathy due to sickle cell disease
  • Nonproliferative retinopathy of left eye due to sickle cell disease
  • Nonproliferative retinopathy of right eye due to sickle cell disease
  • Nonproliferative sickle cell retinopathy
  • Sickle cell retinopathy

Instructional NotesGuidance

Instructions from the official ICD-10-CM Tabular List that apply to H36.813: its own notes plus those printed at H36 and Chapter 7. A note printed at a category, block or chapter applies to every code under it.

Excludes1

Not coded here: the excluded code is never reported together with this one, unless the two conditions are unrelated.

From H36 Retinal disorders in diseases classified elsewhere applies to 9 codes

Excludes2

Not included here: the excluded condition is not part of this code, but a patient may have both, so both codes may be reported.

From Chapter 7 (H00-H59) Diseases of the eye and adnexa applies to 2,677 codes
  • certain conditions originating in the perinatal period (P04-P96)
  • certain infectious and parasitic diseases (A00-B99)
  • complications of pregnancy, childbirth and the puerperium (O00-O9A)
  • congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)
  • diabetes mellitus related eye conditions (E09.3-, E10.3-, E11.3-, E13.3-)
  • endocrine, nutritional and metabolic diseases (E00-E88)
  • injury (trauma) of eye and orbit (S05.-)
  • injury, poisoning and certain other consequences of external causes (S00-T88)
  • neoplasms (C00-D49)
  • symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)
  • syphilis related eye disorders (A50.01, A50.3-, A51.43, A52.71)

Code First

The underlying condition named in the note is sequenced before this code.

From H36 Retinal disorders in diseases classified elsewhere applies to 9 codes
  • underlying disease, such as:
  • lipid storage disorders (E75.-)
  • sickle-cell disorders (D57.-)

Notes

General instructions on how these codes are used.

From Chapter 7 (H00-H59) Diseases of the eye and adnexa applies to 2,677 codes
  • Use an external cause code following the code for the eye condition, if applicable, to identify the cause of the eye condition

Source: CMS ICD-10-CM Tabular List. How to read instructional notes.

Clinical ClassificationClinical

AHRQ’s CCSR groups this code into broader clinical categories.

CCSR EYE005
Retinal and vitreous conditions
Default principal diagnosis: inpatient No · outpatient No
CCSR BLD005
Sickle cell trait/anemia
Default principal diagnosis: inpatient No · outpatient Yes

Patient EducationClinical

Retinal Disorders

Retinal disorders are conditions that affect the retina, the thin light-sensitive tissue at the back of your eye. The retina senses light and sends signals to your brain so you can see.

The full article covers:

  • What are retinal disorders?
  • What causes retinal disorders?
  • What are common retinal disorders?
  • What are the symptoms of retinal disorders?
  • How are retinal disorders diagnosed?
  • How are retinal disorders treated?
  • Can retinal disorders be prevented?

Read the full article at MedlinePlus

Courtesy of MedlinePlus, a service of the U.S. National Library of Medicine.

Code History & ChangesHistory

Replacement H36.813 replaces the following previously assigned code(s):

  • H35.20 - Other non-diabetic proliferative retinopathy, unsp eye
  • H35.21 - Other non-diabetic proliferative retinopathy, right eye
  • H35.22 - Other non-diabetic proliferative retinopathy, left eye
  • H35.23 - Other non-diabetic proliferative retinopathy, bilateral
FY 2024AddedAdded to the ICD-10-CM code setEffective October 1, 2023.
FY 2025–2026No changes
FY 2027CurrentCurrent code set, no changesEffective October 1, 2026 through September 30, 2027.

Questions About H36.813Overview

What is the ICD-10 code for nonproliferative sickle-cell retinopathy, bilateral?

The ICD-10-CM code for nonproliferative sickle-cell retinopathy, bilateral is H36.813 (sometimes written as H36813). It is billable on HIPAA-covered claims from October 1, 2026 through September 30, 2027.

Is H36.813 (Nonproliferative sickle-cell retinopathy) a billable code?

Yes. This is a billable ICD-10-CM code, specific enough to report nonproliferative sickle-cell retinopathy, bilateral on HIPAA-covered claims from October 1, 2026 through September 30, 2027.

What MS-DRG does H36.813 group to?

On inpatient claims, nonproliferative sickle-cell retinopathy, bilateral maps to MS-DRG 125, 124, with relative weights from 0.7699 to 1.2470 depending on complications. Higher weights mean higher Medicare reimbursement.

Can H36.813 be a principal diagnosis?

No. The Medicare Code Editor rejects this code as a principal diagnosis because nonproliferative sickle-cell retinopathy, bilateral describes a circumstance that influences health status rather than a current illness. Report it as a secondary diagnosis.

Can H36.813 be reported with a code from H35.0?

Not as a rule. The Excludes1 note at H36, which applies to H36.813, lists "arteriosclerotic retinopathy (H35.0-)". An Excludes1 note means the excluded code is never reported together with this one; the only exception is when the two conditions are unrelated to each other (Official Guidelines, Section I.A.12.a).

What HCC is H36.813?

H36.813 (nonproliferative sickle-cell retinopathy, bilateral) maps to CMS-HCC Category 108 (Sickle Cell Disorders, Except Sickle Cell Anemia (Hb-SS) and Thalassemia Beta Zero; Beta Thalassemia Major), commonly written as HCC 108, in the CMS-HCC V28 model used for Medicare Advantage risk adjustment in payment year 2027. It mapped to HCC 46 under the retired V24 model. It also maps in the PACE (CMS-HCC V22), ESRD (V21), and ESRD (V24) models. It does not map to any RxHCC in the Part D prescription drug model.

Does H36.813 risk-adjust for Medicare Advantage payment?

Yes. When documented and reported on a Medicare Advantage encounter, H36.813 adds a risk adjustment factor of about 0.146 to the beneficiary's RAF score for a community, non-dual, aged enrollee (published V28 weights range from 0.098 to 0.416 depending on the payment segment). A more severe related category (HCC 107) supersedes it when both are reported. See the full factor table on the HCC 108 category page.