E11.3543: Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E11.3543 is a billable, specific ICD-10-CM code for type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral. It is valid for submission on a claim.
Check E11.3543 with the rest of the claim: free scrubber7th character "3": bilateral
One of the following 7th characters is to be assigned to codes in subcategory E11.35 to designate laterality of the disease:
- 1
- right eye
- 2
- left eye
- 3
- bilateral
- 9
- unspecified eye
Excludes1 inherited from the categories above E11.3543
A category’s note binds every code beneath it.
Written on E11: Type 2 diabetes mellitus
- diabetes mellitus due to underlying condition (E08.-)
- drug or chemical induced diabetes mellitus (E09.-)
- gestational diabetes (O24.4-)
- neonatal diabetes mellitus (P70.2)
- postpancreatectomy diabetes mellitus (E13.-)
- postprocedural diabetes mellitus (E13.-)
- secondary diabetes mellitus NEC (E13.-)
- type 1 diabetes mellitus (E10.-)
Other codes that can never be billed with E11.3543
Their own Excludes1 notes name this code, so the conflict is not listed above.
Risk adjustment
E11.3543 risk-adjusts. Under the CMS-HCC V28 model it maps to these categories:
- HCC 37 Diabetes with Chronic Complications0.166 RAF
- HCC 298 Severe Diabetic Eye Disease, Retinal Vein Occlusion, and Vitreous Hemorrhage0.336 RAF
Coefficient shown for the Community Non-dual Aged segment. A higher HCC in the same hierarchy will suppress this one, so capturing it does not always add score. Look up the whole chart to see which of its HCCs the hierarchy would zero.
Medicare coverage
E11.3543 is named in 56 Medicare coverage policies: 56 listing it as supporting medical necessity, and 1 listing it as NOT covered. Which one applies depends on your Medicare contractor.
- A57069Billing and Coding: Ophthalmic Angiography (Fluorescein and Indocyanine Green)not covered
- A52370Billing and Coding: Bevacizumab and biosimilars
- A52451Billing and Coding: Ranibizumab, Aflibercept and biosimilars
- A52464Glucose Monitor - Policy Article
There’s a guided path to this code
The condition this code belongs to
Code history
Unchanged in every release from FY2024 to FY2027.
Other codes under E11.354
- E11.3541Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
- E11.3542Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
- E11.3549Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye