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H26.001

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🧬ICD-10 CM H26.001 - Unspecified infantile and juvenile cataract, right eye

Overview

ICD-10 CM H26.001 classifies Unspecified infantile and juvenile cataract localized to the right eye. This code is used when a cataract develops during infancy or childhood (juvenile) but the specific type (e.g., zonular, nuclear, cortical) is not documented by the provider. It distinguishes the condition from age-related cataracts (H25.-) and congenital cataracts (Q12.0).

Accurate coding of H26.001 is essential for pediatric ophthalmology claims, ensuring proper tracking of vision impairment in younger populations, and supporting medical necessity for surgical intervention (e.g., lensectomy) when visual development is threatened.

Code Breakdown

The structure of H26.001 follows the ICD-10-CM taxonomy:

SegmentValueDescription
CategoryH26Other cataract
SubcategoryH26.0Infantile and juvenile cataract
ExtensionH26.00Unspecified infantile and juvenile cataract
Laterality1Right eye

Laterality Specifics

  • 1: Right eye
  • 2: Left eye
  • 3: Bilateral
  • 9: Unspecified eye

Laterality Requirement

ICD-10-CM guidelines require specifying laterality for eye conditions whenever documented. If bilateral, use H26.003. If unspecified, use H26.009, though unspecified codes should be avoided when clinical documentation supports specificity.

Coding Guidelines

Includes

  • Cataract occurring in infancy or childhood.
  • Juvenile cataract NOS.
  • Infantile cataract NOS.
  • Developmental cataract (if not specified as congenital).

Excludes

  • Congenital Cataract: Q12.0 (Congenital cataract and lens anomalies). Note: Congenital implies present at birth, whereas infantile/juvenile may develop shortly after.
  • Age-Related Cataract: H25.- (Senile cataract).
  • Complicated Cataract: H26.2 (Cataract due to ocular disorders, diseases in other chapters, or drugs).
  • After-Cataract: H26.4 (Secondary cataract).
  • Diabetic Cataract: E08.36, E09.36, E10.36, E11.36, E13.36 (Cataract associated with diabetes mellitus).

Use of Additional Codes

H26.001 may be coded with additional codes to fully capture the clinical picture:

  • Visual Impairment: If the cataract has resulted in vision loss, add codes from H54.- (Blindness and low vision).
  • Underlying Cause: If the cataract is associated with a systemic condition (e.g., Galactosemia E74.20, Hypoparathyroidism E20.9), code the underlying condition first.
  • Aphakia: If the lens has been removed, add Z96.1 (Presence of intraocular lens) or Z98.4 (Cataract extraction status) if aphakic.
  • External Cause: If the cataract is traumatic, use an external cause code from the External Cause of Injuries Index (e.g., W26.0- for contact with knife) with 7th character for sequelae if applicable ICD-10-CM External Cause of Injuries Index 2025.

Risk Adjustment (HCC)

Hierarchical Condition Category (HCC) status determines impact on risk adjustment scores for Medicare Advantage and ACA plans.

  • HCC Status: No CMS-HCC V28
  • RAF Impact: This code does not directly contribute to the Risk Adjustment Factor (RAF) score under the current CMS-HCC V28 model.
  • Clinical Relevance: While not an HCC, pediatric cataracts are significant vision-threatening conditions requiring urgent intervention to prevent amblyopia. They may trigger care management programs due to surgical needs.

Inpatient Impact (MS-DRG)

In the inpatient setting, H26.001 influences the Medicare Severity Diagnosis Related Group (MS-DRG) assignment.

  • CC/MCC Status: Non-CC (Not a Complication/Comorbidity) CMS MS-DRG v42
  • Impact: This code generally does not shift a DRG to a higher severity tier on its own. Cataract extraction is typically performed in an Ambulatory Surgery Center (ASC) or outpatient hospital setting (APC).
  • POA Indicator: Present on Admission (POA) reporting is required for inpatient claims. Given the developmental nature, it is typically marked Y (Present on Admission).

Code Tree

Chapter 7: Diseases of the Eye and Adnexa (H00-H59)
└── Disorders of lens (H25-H28)
    └── Other cataract (H26)
        └── Infantile and juvenile cataract (H26.0)
            └── Unspecified infantile and juvenile cataract (H26.00)
                └── H26.001 (Right eye)
                └── H26.002 (Left eye)
                └── H26.003 (Bilateral)
                └── H26.009 (Unspecified eye)

Clinical Coding Examples

Example 1: Pediatric Diagnosis

Scenario: A 5-year-old patient presents for routine eye exam. Slit lamp examination reveals opacity in the lens of the right eye. Provider documents “Juvenile cataract, right eye.” Coding:

  • Primary: H26.001
  • Note: If the type (e.g., zonular) was specified, a different code from H26.0 would be used.

Example 2: Bilateral Involvement

Scenario: A 7-year-old patient is diagnosed with infantile cataracts in both eyes. Coding:

Example 3: Associated with Diabetes

Scenario: A 12-year-old patient with Type 1 Diabetes presents with cataract in the right eye. Coding:

  • Primary: E10.36 (Type 1 diabetes mellitus with diabetic cataract)
  • Note: Do not use H26.001 when the cataract is specified as diabetic. The diabetes code includes the cataract manifestation.

Example 4: Post-Surgical Status

Scenario: Patient returns for follow-up after removal of juvenile cataract in the right eye. Pseudophakic. Coding:

  • Primary: Z96.1 (Presence of intraocular lens)
  • Secondary: H26.001 (If the condition is still being monitored/treated) or Z98.4 (Cataract extraction status).

Revenue Cycle Considerations

  • wRVU: Not Applicable. ICD-10-CM codes do not have work Relative Value Units. wRVUs are assigned to CPT/HCPCS procedure codes.
  • Assistant Payable: Not Applicable. This attribute applies to surgical CPT codes.
  • Denial Risk: Moderate. Payers may deny claims if the age of the patient does not support “infantile or juvenile” (e.g., adult patient). Query the provider if an adult is documented with this code.
  • Prior Authorization: Surgical removal of pediatric cataracts often requires prior authorization with documentation supporting visual axis obstruction or risk of amblyopia.
  • H26.002: Unspecified infantile and juvenile cataract, left eye
  • H26.003: Unspecified infantile and juvenile cataract, bilateral
  • H26.009: Unspecified infantile and juvenile cataract, unspecified eye
  • H26.01: Zonular juvenile cataract
  • H26.02: Nuclear juvenile cataract
  • H26.03: Cortical juvenile cataract
  • H26.04: Anterior subcapsular polar juvenile cataract
  • H26.05: Posterior subcapsular polar juvenile cataract
  • Q12.0: Congenital cataract
  • H25.9: Unspecified age-related cataract

Clinical Management Notes

Management of H26.001 typically involves American Academy of Ophthalmology:

  • Observation: If the cataract is small and not affecting visual development.
  • Surgical Removal: Lensectomy with or without intraocular lens (IOL) implantation if the visual axis is obscured.
  • Amblyopia Therapy: Patching or atropine penalization of the fellow eye post-surgery.
  • Optical Correction: Contact lenses or glasses to correct aphakia if no IOL is placed.

Documentation should support the medical necessity of these interventions when billing associated procedure codes (e.g., 66840 for Intracapsular cataract extraction).

CMS ICD-10-CM Official Guidelines for Coding and Reporting FY 2025 CMS-HCC Risk Adjustment Model V28 Summary CMS MS-DRG Definitions Manual v42 NCHS ICD-10-CM Tabular List 2025 American Academy of Ophthalmology Preferred Practice Pattern ICD-10-CM External Cause of Injuries Index 2025

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