E13.3511

E13.3511: Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye

Billable / specific codeICD-10-CM

E13.3511 is a billable, specific ICD-10-CM code for other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye. It is valid for submission on a claim.

Check E13.3511 with the rest of the claim: free scrubber

7th character "1": right eye

One of the following 7th characters is to be assigned to codes in subcategory E13.35 to designate laterality of the disease:

1: right eye
2: left eye
3: bilateral
9: unspecified eye

Excludes1 inherited from the categories above E13.3511

A category’s note binds every code beneath it.

Written on E13: Other specified diabetes mellitus

diabetes (mellitus) due to autoimmune process (E10.-)
diabetes (mellitus) due to immune mediated pancreatic islet beta-cell destruction (E10.-)
diabetes mellitus due to underlying condition (E08.-)
drug or chemical induced diabetes mellitus (E09.-)
gestational diabetes (O24.4-)
neonatal diabetes mellitus (P70.2)
type 1 diabetes mellitus (E10.-)

Other codes that can never be billed with E13.3511

Their own Excludes1 notes name this code, so the conflict is not listed above.

E08Diabetes mellitus due to underlying condition
E09Drug or chemical induced diabetes mellitus
E10Type 1 diabetes mellitus
E11Type 2 diabetes mellitus

Risk adjustment

E13.3511 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

E13.3511 is named in 53 Medicare coverage policies: 53 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

Code history

Unchanged in every release from FY2024 to FY2027.