ICD-10 Coding for Proliferative Diabetic Retinopathy(E11.359, E10.319)
Complete ICD-10-CM coding and documentation guide for Proliferative Diabetic Retinopathy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Proliferative Diabetic Retinopathy
E10.3-E11.3Primary Range
Diabetes mellitus with ophthalmic complications
This range includes codes for diabetes with proliferative diabetic retinopathy, specifying type and complications.
Diabetic macular edema
Used to specify the presence of macular edema in diabetic retinopathy cases.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| E11.359 | Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral | Use when documenting Type 2 DM with bilateral PDR without macular edema. |
|
| E10.319 | Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema | Use when retinopathy is unspecified in Type 1 DM without macular edema. |
|
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 proliferative diabetic retinopathy
Essential facts and insights about Proliferative Diabetic Retinopathy
Primary ICD-10-CM Codes for proliferative diabetic retinopathy
Decision Criteria
clinical Criteria
- Presence of neovascularization without macular edema
Applicable To
- Type 2 DM with PDR without macular edema, bilateral
Excludes
- Type 1 diabetes mellitus with similar complications
Clinical Validation Requirements
- Fundus photography confirming neovascularization
- Absence of macular edema on OCT
Code-Specific Risks
- Incorrectly coding as unspecified PDR
Coding Notes
- Ensure laterality and macular edema status are documented.
E10.319 - Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema
Use when retinopathy is unspecified in Type 1 DM without macular edema.
Applicable To
- Type 1 DM with unspecified retinopathy without macular edema
Excludes
- Type 2 diabetes mellitus with similar complications
Clinical Validation Requirements
- Diabetes type 1 confirmed
- No macular edema present
Coding Notes
Ensure diabetes type is correctly documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Diabetic macular edema
H35.81Differential 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 Proliferative Diabetic Retinopathy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code E11.359.
Impact
Clinical: Inaccurate clinical records, Regulatory: Non-compliance with coding standards, Financial: Potential claim denials
Mitigation Strategy
Always document laterality in exam notes, Use templates to ensure completeness
Impact
Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Always specify laterality and presence of macular edema.
Impact
High risk of audits if unspecified codes are used without proper documentation.
Mitigation Strategy
Use specific codes with complete documentation.
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 Proliferative Diabetic Retinopathy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Proliferative Diabetic Retinopathy
Use these documentation templates to ensure complete and accurate documentation for Proliferative Diabetic Retinopathy. These templates include all required elements for proper coding and billing.
Ophthalmology assessment for PDR
Specialty: OphthalmologyRequired Elements
- Chief complaint
- Past medical history
- Ophthalmic examination
- Imaging results
- Diagnosis and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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