On this page
- What Is the ICD-10 Code for Diabetic Retinopathy?
- How Is a Diabetic Retinopathy Code Built?
- Which Diabetes Type Starts the Code?
- What Are the Severity and Macular Edema Codes?
- How Do You Code Different Findings in Each Eye?
- Which Extra Codes Go With Diabetic Retinopathy?
- Which Procedures Do Diabetic Retinopathy Codes Support?
- Why Do Diabetic Retinopathy Claims Deny?
Key takeaways
- Diabetic retinopathy codes come from the diabetes categories E08 to E13, and E11 is type 2 diabetes.
- The 5th character shows severity, from mild nonproliferative to proliferative, and the 6th shows macular edema.
- The 7th character names the eye, with 1 right, 2 left, 3 both and 9 unspecified.
- If the type of diabetes is not documented, ICD-10-CM guidelines default to type 2 (E11).
What Is the ICD-10 Code for Diabetic Retinopathy?
Diabetic retinopathy is coded with a combination code from the diabetes categories E08 to E13, which reports the diabetes and the eye disease in one code. Type 2 diabetes with retinopathy falls in E11.31 to E11.35.
These codes sit in chapter 4 of ICD-10-CM, not in the eye chapter, so diabetic retinopathy is never coded with an H35 code. They are part of the wider ophthalmology ICD-10 codes list.
How Is a Diabetic Retinopathy Code Built?
A diabetic retinopathy code is built from 4 parts, which are the diabetes type, the retinopathy severity, the macular edema status and the eye. The table breaks down E11.3293.
| Part of the code | Characters | Example E11.3293 |
|---|---|---|
| Diabetes type | E08, E09, E10, E11 or E13 | E11, type 2 diabetes |
| Severity | 4th and 5th characters, .31 to .35 | .32, mild nonproliferative |
| Macular edema | 6th character | 9, without macular edema |
| Eye | 7th character | 3, both eyes |
A code without its 7th character is incomplete and rejects, except for E11.311 and E11.319, which have no eye character.
Which Diabetes Type Starts the Code?
The first 3 characters show the type of diabetes, and the record must name it. When the type is not documented, ICD-10-CM guidelines default to type 2, E11.
- E08 for diabetes due to an underlying condition
- E09 for drug or chemical induced diabetes
- E10 for type 1 diabetes
- E11 for type 2 diabetes
- E13 for other specified diabetes
The rest of the code follows the same pattern in every category, so E10.3293 is the type 1 version of E11.3293.
What Are the Severity and Macular Edema Codes?
The severity codes run from unspecified retinopathy (.31) through mild, moderate and severe nonproliferative (.32 to .34) to proliferative (.35), and the 6th character shows macular edema. The table uses type 2 diabetes and the right eye.
| Severity | With macular edema | Without macular edema |
|---|---|---|
| Unspecified retinopathy | E11.311 | E11.319 |
| Mild nonproliferative | E11.3211 | E11.3291 |
| Moderate nonproliferative | E11.3311 | E11.3391 |
| Severe nonproliferative | E11.3411 | E11.3491 |
| Proliferative | E11.3511 | E11.3591 |
Change the last character for the other eyes, 2 for the left, 3 for both and 9 for unspecified.
Which codes describe advanced proliferative disease?
Proliferative retinopathy has 4 more 6th character options. E11.352- is traction retinal detachment involving the macula, E11.353- is traction detachment not involving the macula, E11.354- is combined traction and rhegmatogenous detachment and E11.355- is stable proliferative retinopathy.
How is resolved macular edema coded?
E11.37X- reports diabetic macular edema that has resolved after treatment, with the eye in the 7th character, such as E11.37X1 for the right eye. Use it when the edema is gone but the patient is still followed for it.
How Do You Code Different Findings in Each Eye?
Use the bilateral 7th character only when both eyes have the same severity and edema status, and code each eye on its own when they differ. These examples cover the common cases.
| Findings | Codes |
|---|---|
| Moderate NPDR without edema in both eyes | E11.3393 |
| Moderate NPDR with edema right eye, without edema left eye | E11.3311 and E11.3392 |
| PDR without edema right eye, severe NPDR without edema left eye | E11.3591 and E11.3492 |
Separate codes also let each procedure line point to the eye it treated.
Which Extra Codes Go With Diabetic Retinopathy?
Add a long-term drug code for insulin or other diabetes drugs, and code other diabetic eye problems with their own combination codes. These are the extra codes used most often.
- Z79.4 for long-term insulin use
- Z79.84 for long-term oral diabetes drugs
- Z79.85 for long-term injectable non-insulin diabetes drugs
- E11.36 for diabetic cataract
- E11.9 for type 2 diabetes with no complications, when the eye exam finds no retinopathy
A diabetic eye exam with normal findings is still a medical visit, coded with the diabetes code, not a routine exam code.
Which Procedures Do Diabetic Retinopathy Codes Support?
Diabetic retinopathy codes support retinal imaging, intravitreal injections for macular edema and laser treatment, and each service has its own covered diagnosis list. The table pairs common services with the usual codes.
| Service | CPT code | Usual diagnosis |
|---|---|---|
| OCT of the retina | 92134 | Retinopathy with or without macular edema |
| Fundus photography | 92250 | Any documented retinopathy |
| Intravitreal injection | 67028 | Retinopathy with macular edema, or proliferative disease |
| Panretinal photocoagulation | 67228 | Proliferative or severe nonproliferative retinopathy |
| Fluorescein angiography | 92235 | Suspected neovascularization or macular edema |
Check the payer's coverage policy for each drug and test. Our retina billing services team matches every injection to a covered code.
Why Do Diabetic Retinopathy Claims Deny?
Diabetic retinopathy claims deny most often because the code is missing its eye character, uses an H35 code or does not match the treated eye. These checks prevent most of them.
- Full code. Staged codes have 7 characters.
- Right category. Use E08 to E13, never H35.
- Matching eye. The eye in the code matches RT or LT on the procedure.
- Current findings. Severity and edema match the exam on that date.
Our ophthalmology medical coding services check every diabetic eye claim for these points before it is sent.