Crystal's MCW Coder Hub⚕️ICD-10-CM E11.311 - Type 2 Diabetes Mellitus with Unspecified Diabetic Retinopathy with Macular Edema
Full Official Descriptor: Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
ICD-10-CM Chapter: Chapter 4 - Endocrine, Nutritional and Metabolic Diseases (E00-E89) Block: E11 - Type 2 Diabetes Mellitus Billable/Specific Code: ✅ Yes — valid and billable FY2024-FY2026 Laterality: ⚠️ Unspecified — no eye laterality specified (no 7th character)
⚠️ Critical Coder Alert — “Unspecified” Code Considerations
E11.311 is unique within the E11.3x retinopathy family because it carries only 6 characters — meaning it has no 7th character for laterality. Unlike the more specific sibling codes (e.g., E11.3211, E11.3311, E11.3411 which carry right/left/bilateral designators), E11.311 does not specify which eye is affected.
⚠️ Best Practice: Per ICD-10-CM Official Guidelines Section I.B.13 and AAPC/AHA coding guidance, unspecified codes should only be used when the documentation genuinely does not support a more specific code. If the treating provider has documented which eye has retinopathy and/or macular edema, a laterality-specific code should be assigned instead. E11.311 is appropriate when:
- The retinopathy stage is genuinely not documented (no mild/moderate/severe/proliferative staging)
- Laterality is truly not determinable from the record
- The provider’s note only states “diabetic retinopathy with macular edema” without further detail
💡 Query Opportunity: If the clinical record contains imaging (OCT, fundus photo, FA) that reveals the specific eye affected and the severity stage, the coder should query the physician to clarify both the retinopathy stage and laterality before defaulting to E11.311. In most ophthalmology and retina practice settings, this code is a stepping stone to a more specific code — not a final destination.
🔬 Clinical Overview
Type 2 Diabetes Mellitus (T2DM)
Type 2 Diabetes Mellitus is characterized by a combination of insulin resistance and relative insulin deficiency. Unlike Type 1 DM, beta-cell destruction is not immune-mediated; instead, peripheral tissues fail to respond appropriately to insulin and the pancreatic beta cells cannot compensate adequately over time. T2DM is coded under the E11.- category in ICD-10-CM.
Key ICD-10-CM distinctions for T2DM:
- Includes: Diabetes mellitus due to insulin secretory defect, diabetes NOS, insulin-resistant diabetes mellitus
- T2DM does not assume or require insulin use — but when the patient IS on insulin, Z79.4 must be assigned additionally
- If the type of diabetes is not documented, default to E11.- per ICD-10-CM guideline I.C.4.a.2
Diabetic Retinopathy (DR) — General
Chronic hyperglycemia in T2DM leads to progressive retinal microvascular damage through multiple pathways: pericyte loss, basement membrane thickening, endothelial cell dysfunction, increased vascular permeability, capillary occlusion, and release of pro-angiogenic factors (VEGF). This microvascular injury produces the full spectrum of diabetic retinopathy — from early microaneurysm formation to end-stage proliferative disease with vitreous hemorrhage and traction retinal detachment.
Diabetic Macular Edema (DME)
Diabetic Macular Edema (DME) is the leading cause of vision impairment in patients with diabetic retinopathy of any stage. It results from breakdown of the inner blood-retinal barrier with leakage of fluid, lipids, and plasma proteins into the macula — the central, high-acuity region of the retina responsible for fine visual tasks (reading, driving, face recognition).
DME can occur at any stage of diabetic retinopathy — from mild NPDR all the way through PDR — and is independent of the retinopathy severity classification. This is a critical clinical and coding concept: the presence of macular edema must be independently documented and coded, regardless of the retinopathy stage.
| Feature | Non-Center-Involving DME | Center-Involving DME (CI-DME) |
|---|---|---|
| Location | Edema outside the central subfield | Edema involving the central 1mm zone |
| Visual Impact | May preserve central acuity | High risk of central vision loss |
| OCT Finding | Thickening peripheral to fovea | Central subfield thickness (CST) increased; subretinal fluid possible |
| Primary Treatment | Observation or laser | Anti-VEGF injection (first line) |
| ICD-10 Coding | DME present = “1” in 6th position | Same code — DME presence/absence is binary in ICD-10 |
📌 ICD-10 Coding Note: ICD-10-CM does not distinguish between center-involving and non-center-involving DME within the code itself. Both types of macular edema map to the “with macular edema” (6th character = 1) designation. The distinction is clinically critical for treatment selection but is not yet codeable separately in ICD-10-CM — it is captured in the clinical notes and OCT documentation.
📋 Code Details
| Field | Detail |
|---|---|
| ICD-10-CM Code | E11.311 |
| Full Descriptor | Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema |
| Chapter | Chapter 4 - Endocrine, Nutritional and Metabolic Diseases |
| Block | E11 - Type 2 Diabetes Mellitus |
| Parent Code | E11.31- (non-billable — “unspecified retinopathy” header, requires additional character) |
| Billable | ✅ Yes |
| Laterality | ⚠️ Unspecified — no eye specified; 6-character code only |
| Retinopathy Stage | ⚠️ Unspecified — no severity stage documented |
| Macular Edema Present? | ✅ Yes — “with macular edema” is explicit in descriptor |
| wRVU | N/A — diagnosis code |
| Assistant Payable | N/A — diagnosis code |
| Valid FY | FY2024 - FY2026 (confirmed active) |
| POA Indicator Required | ✅ Yes — inpatient UB-04 claims |
| Chronic Condition Indicator | Chronic |
| Code Type | Combination code — captures T2DM + retinopathy + DME (stage and laterality unspecified) |
📌 Why This Code Exists: E11.311 serves as a catch-all for T2DM with retinopathy and macular edema when clinical documentation lacks staging specificity or laterality detail. It is commonly used in primary care and internal medicine settings where the provider documents “diabetic macular edema” or “diabetic retinopathy with macular edema” without ophthalmic-level staging detail. In ophthalmology/retina settings, it should be a red flag for a documentation query — the clinical record almost always supports a more specific code.
✅ Includes / Use Additional Code Instructions
Included Within E11.311
Per ICD-10-CM tabular, E11 includes:
- Diabetes (mellitus) due to insulin secretory defect
- Diabetes NOS (not otherwise specified)
- Insulin-resistant diabetes mellitus
- Type 2 diabetes mellitus (unspecified retinopathy stage, with macular edema, unspecified laterality)
Use Additional Codes (Per ICD-10-CM Tabular Instruction, E11.-)
| Additional Code | Description | Application |
|---|---|---|
| Z79.4 | Long-term (current) use of insulin | Apply when T2DM patient is on insulin therapy — NOT assumed for T2DM (unlike T1DM); only code when documented |
| Z79.84 | Long-term use of oral antidiabetic drugs | Apply when patient uses oral agents (metformin, SGLT2 inhibitors, DPP-4 inhibitors, sulfonylureas, etc.) |
| Z79.85 | Long-term use of injectable non-insulin antidiabetic drugs | Apply for GLP-1 agonists (semaglutide, dulaglutide, liraglutide) — increasingly relevant with newer T2DM management |
| Z83.3 | Family history of diabetes mellitus | Optional; useful in preventive/risk coding |
| H35.81 | Retinal edema | Only if retinal edema is separately documented and clinically distinct from the DME already captured in E11.311 |
📌 Z79.4 T2DM vs. T1DM Distinction: For T2DM (E11.-), insulin use is NOT assumed — it must be explicitly documented in the record to assign Z79.4. This is a key distinction from T1DM, where insulin dependence is inherent. For patients on both insulin AND oral agents, assign both Z79.4 and Z79.84.
🚫 Excludes
Excludes 1 (Mutually Exclusive — Cannot Code Together)
| Code | Description |
|---|---|
| E08.- | Diabetes mellitus due to underlying condition |
| E09.- | Drug or chemical induced diabetes mellitus |
| E10.- | Type 1 diabetes mellitus |
| E13.- | Other specified diabetes mellitus |
| O24.4- | Gestational diabetes mellitus |
| P70.2 | Neonatal diabetes mellitus |
⚠️ If documentation supports T1DM, use E10.311 (T1DM with unspecified DR with macular edema) — not E11.311. However, per ICD-10-CM Guideline I.C.4.a.2: “If the type of DM is not documented, default to Type 2 (E11.-).” This guideline protects coders when provider documentation is ambiguous.
Excludes 2 (May Code Together When Documented)
| Code | Description |
|---|---|
| H36.- | Retinal disorders in diseases classified elsewhere |
| N18.- | Chronic kidney disease |
| G63 | Polyneuropathy in diseases classified elsewhere |
🏷️ HCC Risk Adjustment Mapping
E11.311 is an HCC-mapped diagnosis. Annual documentation and claim submission are required to maintain risk adjustment credit under Medicare Advantage.
CMS-HCC Version 24 (V24) — Reference / Historical
| HCC | Category Name | RAF Contribution (approx.) |
|---|---|---|
| HCC 18 | Diabetes with Ophthalmologic Manifestations | ~0.200 (Community, Non-Dual, Aged) |
Under V24, E11.311 contributed to HCC 18, distinct from uncomplicated diabetes (HCC 19, ~0.105 RAF). The ophthalmic complication carried meaningful incremental RAF.
CMS-HCC Version 28 (V28) — Fully Active 2026
| HCC | Category Name | RAF Contribution (approx.) |
|---|---|---|
| HCC 38 | Diabetes with Ophthalmologic or Unspecified Manifestation | ~0.166 (Constrained) |
⚠️ V28 Constraining — Same Coefficient Across All DM Categories: Under V28 (100% implemented in 2026), all diabetes HCC categories — including E11.311 — contribute the same RAF coefficient of approximately 0.166, regardless of whether the patient has uncomplicated T2DM (E11.9) or T2DM with macular edema (E11.311). The financial premium for coding complications was eliminated in the V28 transition.
💡 V28 Unintended Consequence for E11.311: Because E11.311 is an unspecified code (no laterality, no staging), it still maps to HCC 38 — the same as if a coder had used E11.3411 (severe NPDR with DME, right eye). From a pure HCC RAF perspective in V28, the two codes are equivalent. However, the clinical accuracy, audit defensibility, quality measure performance, and medical necessity documentation all favor using the most specific code. Never use V28 RAF equivalence as justification to remain at an unspecified code.
🏥 MS-DRG Applicability
MS-DRG: ✅ Applicable for Inpatient Stays
E11.311 maps to MDC 10 (Endocrine, Nutritional and Metabolic Diseases) MS-DRGs under CMS MS-DRG V43.0 (FY2026):
| MS-DRG | Title | Trigger Condition |
|---|---|---|
| 637 | Diabetes with MCC | E11.311 as principal DX + qualifying MCC |
| 638 | Diabetes with CC | E11.311 as principal DX + qualifying CC |
| 639 | Diabetes without CC/MCC | E11.311 as principal DX, no CC/MCC |
📌 Inpatient Use Note: E11.311 as a standalone principal diagnosis is uncommon in inpatient settings — T2DM with unspecified retinopathy and DME would rarely precipitate an acute admission. More commonly it appears as a secondary diagnosis alongside a principal diagnosis of DKA (E11.00, E11.01), hyperosmolarity (E11.00), cellulitis, ACS, or a retinal surgical procedure. As a secondary diagnosis, it may contribute CC status depending on the CMS CC/MCC list for the applicable DRG grouper version — elevating reimbursement from DRG 639 to DRG 638.
POA Indicator: For chronic pre-existing T2DM with DME — Y (Yes) in virtually all cases.
🌳 Code Tree
E11.311 in Context — E11.3x Full Retinopathy Family
E11 - Type 2 Diabetes Mellitus (non-billable)
│
└── E11.3 - T2DM with diabetic retinopathy (non-billable)
│
├── E11.31 - T2DM with UNSPECIFIED diabetic retinopathy (non-billable header)
│ ├── E11.311 - T2DM with unspecified DR WITH macular edema ← YOU ARE HERE
│ └── E11.319 - T2DM with unspecified DR WITHOUT macular edema
│
├── E11.32 - T2DM with mild NPDR (non-billable header)
│ ├── E11.3211 - Mild NPDR with ME, right eye
│ ├── E11.3212 - Mild NPDR with ME, left eye
│ ├── E11.3213 - Mild NPDR with ME, bilateral
│ ├── E11.3219 - Mild NPDR with ME, unspecified eye
│ ├── E11.3291 - Mild NPDR without ME, right eye
│ ├── E11.3292 - Mild NPDR without ME, left eye
│ ├── E11.3293 - Mild NPDR without ME, bilateral
│ └── E11.3299 - Mild NPDR without ME, unspecified eye
│
├── E11.33 - T2DM with moderate NPDR (non-billable header)
│ ├── E11.3311 - Moderate NPDR with ME, right eye
│ ├── E11.3312 - Moderate NPDR with ME, left eye
│ ├── E11.3313 - Moderate NPDR with ME, bilateral
│ ├── E11.3319 - Moderate NPDR with ME, unspecified eye
│ ├── E11.3391 - Moderate NPDR without ME, right eye
│ ├── E11.3392 - Moderate NPDR without ME, left eye
│ ├── E11.3393 - Moderate NPDR without ME, bilateral
│ └── E11.3399 - Moderate NPDR without ME, unspecified eye
│
├── E11.34 - T2DM with severe NPDR (non-billable header)
│ ├── E11.3411 - Severe NPDR with ME, right eye
│ ├── E11.3412 - Severe NPDR with ME, left eye
│ ├── E11.3413 - Severe NPDR with ME, bilateral
│ ├── E11.3419 - Severe NPDR with ME, unspecified eye
│ ├── E11.3491 - Severe NPDR without ME, right eye
│ ├── E11.3492 - Severe NPDR without ME, left eye
│ ├── E11.3493 - Severe NPDR without ME, bilateral
│ └── E11.3499 - Severe NPDR without ME, unspecified eye
│
├── E11.35 - T2DM with proliferative DR (non-billable header)
│ ├── E11.3511 - PDR with ME, right eye
│ ├── E11.3512 - PDR with ME, left eye
│ ├── E11.3513 - PDR with ME, bilateral
│ ├── E11.3519 - PDR with ME, unspecified eye
│ ├── E11.3521 - PDR with TRD involving macula, right eye
│ ├── E11.3522 - PDR with TRD involving macula, left eye
│ ├── E11.3531 - PDR with TRD not involving macula, right eye
│ ├── E11.3532 - PDR with TRD not involving macula, left eye
│ ├── E11.3541 - PDR with combined TRD + RRD, right eye
│ ├── E11.3542 - PDR with combined TRD + RRD, left eye
│ ├── E11.3551 - Stable PDR, right eye
│ ├── E11.3552 - Stable PDR, left eye
│ ├── E11.3553 - Stable PDR, bilateral
│ ├── E11.3591 - PDR without ME, right eye
│ ├── E11.3592 - PDR without ME, left eye
│ ├── E11.3593 - PDR without ME, bilateral
│ └── E11.3599 - PDR without ME, unspecified eye
│
└── E11.37 - T2DM with diabetic macular edema, resolved following treatment
├── E11.37X1 - DME resolved, right eye
├── E11.37X2 - DME resolved, left eye
├── E11.37X3 - DME resolved, bilateral
└── E11.37X9 - DME resolved, unspecified eye
T2DM Retinopathy Progression Table (With vs. Without Macular Edema)
| Stage | With Macular Edema | Without Macular Edema |
|---|---|---|
| Unspecified DR | E11.311 ← YOU ARE HERE | E11.319 |
| Mild NPDR (right eye) | E11.3211 | E11.3291 |
| Moderate NPDR (right eye) | E11.3311 | E11.3391 |
| Severe NPDR (right eye) | E11.3411 | E11.3491 |
| Active PDR (right eye) | E11.3511 | E11.3591 |
| Stable PDR (right eye) | E11.3551 | E11.3551 |
| DME Resolved (right eye) | E11.37X1 | — |
Tip
📌 Use E11.311 only when retinopathy stage AND/OR laterality cannot be determined from documentation. Otherwise, move down the table to the most specific code available.
🔗 Associated CPT Procedure Codes
E11.311 is a diagnosis code — it drives medical necessity for the following CPT procedures:
Diagnostic and Imaging
| CPT Code | Description | wRVU |
|---|---|---|
| 92134 | OCT of retina, unilateral or bilateral, with interpretation and report | 0.65 |
| 92235 | Fluorescein angiography with interpretation and report | 1.00 |
| 92250 | Fundus photography with interpretation and report | 0.44 |
| 92228 | Remote imaging of retina, physician interpretation, low complexity | 0.42 |
| 92229 | Imaging of retina, point-of-care autonomous analysis | — |
Evaluation and Management
| CPT Code | Description | wRVU |
|---|---|---|
| 92004 | Comprehensive ophthalmological exam, new patient | 2.00 |
| 92014 | Comprehensive ophthalmological exam, established patient | 1.34 |
| 99213 | Office/outpatient visit, established, low complexity | 0.97 |
| 99214 | Office/outpatient visit, established, moderate complexity | 1.50 |
| 99215 | Office/outpatient visit, established, high complexity | 2.11 |
Treatment — Anti-VEGF / Laser / Surgical
| CPT Code | Description | wRVU | Notes |
|---|---|---|---|
| 67028 | Intravitreal injection of pharmacologic agent | 0.72 | Primary treatment for CI-DME — anti-VEGF agents (bevacizumab, aflibercept, ranibizumab, faricimab/Vabysmo, brolucizumab, high-dose aflibercept/EYLEA HD) |
| 67210 | Photocoagulation, retinal; focal or grid laser | 5.31 | Focal/grid laser for non-CI-DME or cases not responding to anti-VEGF |
| 67228 | Panretinal photocoagulation (PRP) for extensive/progressive retinopathy | 7.29 | Used if DR advances to severe NPDR or PDR alongside DME treatment |
| 67036 | Vitrectomy, mechanical, pars plana | 14.97 | For DME refractory to anti-VEGF with vitreomacular traction component |
📌 Anti-VEGF Coding Tip: When billing 67028 for DME treatment, the drug J-code for the specific anti-VEGF agent is billed in addition to 67028 on the same claim line. Common J-codes:
- J0178 - Aflibercept (EYLEA, EYLEA HD)
- J9035 - Bevacizumab (Avastin — off-label)
- J2778 - Ranibizumab (Lucentis)
- J0172 - Faricimab-svoa (Vabysmo)
- J0179 - Brolucizumab-dbll (Beovu)
E11.311 is accepted as a covered diagnosis for all major payer anti-VEGF authorization criteria for DME, though specific payers may require more specific staging codes for prior authorization approval.
💡 Coding Examples
Example 1 - Primary Care Encounter (Unspecified Staging, Legitimate Use)
A 67-year-old established patient with T2DM (on metformin and insulin) is seen by their internist for diabetes management. The physician documents in the assessment: “Type 2 DM with diabetic retinopathy and macular edema — referred to ophthalmology.” No staging or laterality is specified. No retinal imaging is available in the record.
Bill:
- 99214 (Office visit, established, moderate complexity)
- E11.311 (T2DM with unspecified DR with macular edema — appropriate here; staging not documented by this provider)
- Z79.4 (Long-term use of insulin — patient is on insulin)
- Z79.84 (Long-term use of oral antidiabetic drugs — patient on metformin)
✅ This is a legitimate use of E11.311 — the primary care provider has not staged the retinopathy and lacks ophthalmic imaging to do so. The referral to ophthalmology will ideally generate a more specific code.
Example 2 - Ophthalmology Encounter (Should NOT Use E11.311 — Query Opportunity)
A 71-year-old established patient at a retina practice is seen for monitoring of known DME. OCT in the chart shows central subfield thickening in the right eye consistent with center-involving DME. The fundus exam documents dot/blot hemorrhages and microaneurysms in the right eye — consistent with moderate NPDR. The physician’s assessment states: “Diabetic macular edema.” No staging or laterality documented in assessment section.
Incorrect (Unacceptable in Ophthalmology Setting):
- E11.311 ← ⚠️ Do not use; clinical documentation supports a far more specific code
Correct Action — Query Provider:
- Query: “Documentation and OCT support moderate NPDR with center-involving DME, right eye. Can you confirm E11.3311 (T2DM with moderate NPDR with macular edema, right eye)?”
Bill After Query Confirms:
- 92014--25 (Comprehensive exam, established; modifier -25 for same-day OCT)
- 92134 (OCT of retina)
- E11.3311 (T2DM with moderate NPDR with macular edema, right eye)
- Z79.84 (Long-term oral antidiabetic drugs — if applicable)
📝 In any ophthalmology or retina setting, defaulting to E11.311 when clinical notes, imaging, and exam findings support a specific staging and laterality is a documentation quality failure that can trigger payer audits and medical necessity denials.
Example 3 - Same-Day Anti-VEGF Injection for DME
An established retina patient with T2DM returns for intravitreal anti-VEGF injection (faricimab) for persistent center-involving DME right eye. OCT is performed prior to injection. Physician documents “T2DM with DME, right eye” — no staging mentioned. Patient is on oral antidiabetic agents only (no insulin).
Interim Bill (Unspecified — Query Pending):
- 99214--25 (E/M; modifier -25)
- 92134 (OCT pre-injection)
- 67028--RT (Intravitreal injection, right eye)
- J0172 x1 (Faricimab-svoa/Vabysmo drug J-code)
- E11.311 (Temporary — pending physician clarification of staging)
- Z79.84 (Long-term oral antidiabetic drugs)
After Provider Query + Clarification:
- Replace E11.311 with E11.3311 (T2DM with moderate NPDR with macular edema, right eye) if staging confirmed
⚠️ Some commercial payers require a specific staging code (not “unspecified”) for prior authorization of anti-VEGF injections for DME. E11.311 may cause a prior auth denial with certain payers — always confirm payer-specific DME coverage criteria.
Example 4 - Resolved DME — Code Must Change
At the 6-month follow-up, the same patient from Example 3 has OCT showing complete resolution of macular edema in the right eye following anti-VEGF treatment. The physician documents: “DME resolved, right eye.”
Bill:
- 92014 (Comprehensive exam, established)
- 92134 (OCT)
- E11.37X1 ← Code MUST CHANGE from E11.311 to E11.37X1 (T2DM with DME resolved following treatment, right eye)
- Z79.84 (Long-term oral antidiabetic drugs)
Warning
Example 5 - Inpatient Secondary Diagnosis (Bilateral DME, Unspecified Staging)
A 74-year-old T2DM patient is admitted for surgical management of a hip fracture. The H&P notes pre-existing “diabetic retinopathy with macular edema, both eyes” in the problem list. No ophthalmology consult is obtained; no imaging is performed during admission. The attending documents the condition as an active comorbidity.
Principal Diagnosis: S72.001A (Fracture of right femoral neck, unspecified, initial encounter — or appropriate fracture code)
Secondary Diagnosis:
- E11.311 (T2DM with unspecified DR with macular edema — appropriate as unspecified since no ophthalmic staging was performed during this admission)
- Z79.84 or Z79.4 as applicable
POA: Y (Yes) — pre-existing chronic condition
📝 In the inpatient setting where an ophthalmologist has not evaluated the patient and no retinal imaging exists in the chart, E11.311 is acceptable as a secondary diagnosis. It is preferable to the non-specific E11.9 and accurately captures both the retinopathy and the DME as documented by the attending.
📎 Documentation Requirements
For E11.311 to be correctly applied — and to support upgrading to a more specific code — the medical record should address:
- Type of diabetes — explicitly documented as Type 2 (or “diabetes NOS” / “diabetes mellitus” without further specification, which defaults to Type 2)
- Retinopathy present — “diabetic retinopathy” or equivalent language linking retinal disease to the diabetes
- Macular edema present — “macular edema,” “DME,” “diabetic macular edema,” “clinically significant macular edema (CSME),” “cystoid macular edema due to DM,” or similar
- For upgrading to specific code — staging (mild/moderate/severe NPDR, PDR) and laterality (right/left/bilateral) must be explicitly stated or determinable from imaging
- Insulin and oral medication use — document to support Z79.4 and/or Z79.84
- Causal linkage — retinopathy attributed to diabetes; documentation of “diabetic retinopathy” inherently establishes this per ICD-10-CM guidelines (no explicit “due to” language required for DM ophthalmic complications)
⚠️ Coding Guideline Reminder (ICD-10-CM I.C.4.a.2): A causal relationship between T2DM and any diabetic ophthalmic complication should be assumed (coded as related) unless the provider explicitly states the conditions are unrelated. You do NOT need the physician to write “due to diabetes” — “diabetic macular edema” or “diabetic retinopathy” is sufficient to establish the E11 combination code.
🔁 Payer and Compliance Considerations
- Medicare Advantage (HCC V28): E11.311 maps to HCC 38 — must be submitted on an eligible face-to-face encounter at least once per calendar year to receive RAF credit; ophthalmology claims are MA-eligible
- Anti-VEGF Prior Authorization: E11.311 is on the approved DME diagnosis code lists for bevacizumab, aflibercept, ranibizumab, faricimab, and brolucizumab per major payer clinical criteria (Carelon, UHC, BCBS); however, some payers may require a more specific staging code for approval — verify payer by payer
- MIPS Measure #117 (Diabetes: Eye Exam): E11.311 paired with a qualifying exam CPT qualifies for this MIPS numerator — important for ophthalmology, optometry, and PCP MIPS performance
- Avoid Overuse in Ophthalmology Settings: Use of E11.311 in a retina or ophthalmology practice where more specific codes are clearly supported constitutes undercoding — which, while not fraudulent, is a documentation quality risk and may trigger payer requests for medical records
- ICD-10-CM Annual Update — October 1: Verify annually; the E11.3x diabetic retinopathy family has been stable but review CMS tabular addenda each FY
Sources: AAPC Codify E11.311 · FindACode E11.311 · ICD List E11.311 2026 · SOAPsuds E11.311 · Retinal Physician Coding Diabetic Patients June 2025 · Eyes on Eyecare OD DR Billing Guide 2025 · Genentech SUSVIMO DME Billing Codes · Genentech VABYSMO DME Billing Codes · EYLEA HD ICD-10 Billing Coding Guide · CarelonRx VEGF Clinical Criteria PDF · BCBSND Intravitreal Injections Policy · CMS ICD-10-CM Official Guidelines FY2019 (I.C.4) · CMS SCODI Article 56916 · CMS HCC V28 2026 Software/ICD-10 Mappings · Wolters Kluwer V28 RAF Impact Analysis · ForvisMazars V28 Risk Adjustment Implications · Keebler Health V28 Analysis · AAPC CMS-HCC V28 Knowledge Center · PatientNotes.ai Diabetes ICD-10 2026 · AMA CPT 2025-2026