ICD-10 Coding for Diabetic Retinopathy(E11.3293, E11.3413)
Complete ICD-10-CM coding and documentation guide for Diabetic Retinopathy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Diabetic Retinopathy
E08-E13Primary Range
Diabetes mellitus codes with ophthalmic complications
This range includes codes for diabetes with complications affecting the eyes, such as retinopathy.
Retinal disorders
This range includes specific codes for retinal disorders, including those related to diabetes.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| E11.3293 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral | Use when documenting mild NPDR without macular edema in both eyes. |
|
| E11.3413 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral | Use when severe NPDR and macular edema are documented in both eyes. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for diabetic retinopathy
Essential facts and insights about Diabetic Retinopathy
Primary ICD-10-CM Codes for diabetic retinopathy
Decision Criteria
clinical Criteria
- Documented absence of macular edema and presence of mild NPDR.
Applicable To
- Mild NPDR without macular edema, bilateral
Excludes
- Proliferative diabetic retinopathy
Clinical Validation Requirements
- Fundus exam showing microaneurysms
- Absence of macular edema on OCT
Code-Specific Risks
- Risk of undercoding if macular edema is present but not documented.
Coding Notes
- Ensure documentation specifies the absence of macular edema.
E11.3413 - Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
Use when severe NPDR and macular edema are documented in both eyes.
Applicable To
- Severe NPDR with macular edema, bilateral
Excludes
- Proliferative diabetic retinopathy
Clinical Validation Requirements
- Fundus exam showing severe NPDR changes
- OCT confirming macular edema
Coding Notes
Ensure documentation specifies the presence of macular edema.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Long-term (current) use of insulin
Z79.4Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Diabetic Retinopathy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code E11.3293.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims.
Mitigation Strategy
Always specify which eye(s) are affected., Use bilateral codes when applicable.
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases the accuracy of health records.
Mitigation Strategy
Always document and code the specific type and severity of retinopathy.
Impact
Coding does not match documented clinical findings.
Mitigation Strategy
Regular training on documentation and coding standards.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Diabetic Retinopathy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Diabetic Retinopathy
Use these documentation templates to ensure complete and accurate documentation for Diabetic Retinopathy. These templates include all required elements for proper coding and billing.
Ophthalmology visit for diabetic retinopathy
Specialty: OphthalmologyRequired Elements
- Visual acuity
- Fundus exam findings
- OCT results
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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