🧬 ICD-10 CM E11.319 — Type 2 Diabetes Mellitus With Unspecified Diabetic Retinopathy Without Macular Edema
Billable Code Confirmed
ICD-10 CM E11.319 is a fully billable 6-character ICD-10-CM code, valid for FY2026 discharges and encounters. The code breaks down as: E11 (Type 2 diabetes mellitus) → .3 (with ophthalmic complications) → 1 (unspecified diabetic retinopathy) → 9 (without macular edema). The 6th character “9” is required and indicates the absence of macular edema, distinguishing this code from E11.311, which specifies unspecified retinopathy with macular edema. No additional 7th character is required at this subcategory level, making E11.319 complete and billable as written.
Non-Billable Parent Codes
E11 (Type 2 diabetes mellitus) is a non-billable category header requiring additional characters to specify the complication or manifestation. E11.3 (Type 2 diabetes mellitus with ophthalmic complications) is a non-billable subcategory header — it identifies the body system affected but does not specify the type of retinopathy or the macular edema status. E11.31 (Type 2 diabetes mellitus with unspecified diabetic retinopathy) is also non-billable because the 6th character indicating macular edema status (“1” for with, “9” for without) has not yet been appended; it will be rejected on claims if reported in place of E11.319.
Clinical Context
ICD-10 CM E11.319 is a combination code that captures both the type of diabetes and the ophthalmic complication in a single code per ICD-10-CM Official Coding Guidelines Section I.C.4.a — no separate code for the retinopathy is assigned. The “unspecified” designation reflects that the treating provider has documented diabetic retinopathy but has not characterized it as nonproliferative (mild, moderate, severe) or proliferative, which is common in non-ophthalmologic settings or when imaging results are pending. This code should not be defaulted to when the medical record contains ophthalmology reports that specify the retinopathy stage — in that scenario, the most specific code (e.g., E11.3211, E11.3311, E11.3411) must be used. A CDI query is appropriate when the admitting or treating physician documents “diabetic retinopathy” without staging, and an ophthalmology consult note in the same encounter does specify the stage.
Code Classification
ICD-10 CM E11.319 is an ICD-10-CM diagnosis code — it is not a procedure code and has no CPT or ICD-10-PCS equivalent. It is classified under Chapter 4 of ICD-10-CM (Endocrine, Nutritional and Metabolic Diseases, E00-E89) and represents a chronic metabolic disease complicated by a microvascular ophthalmic complication.
🔍 Code Description
ICD-10 CM E11.319 classifies type 2 diabetes mellitus (T2DM) in a patient who has developed diabetic retinopathy — damage to the microvasculature of the retina caused by chronic hyperglycemia — where the retinopathy has been documented but not further staged, and where macular edema is explicitly absent or not documented. The pathophysiology involves prolonged glucose toxicity causing pericyte loss, basement membrane thickening, breakdown of the blood-retinal barrier, and eventual formation of microaneurysms, dot-blot hemorrhages, and exudates in the retinal layers. Because the macular edema status is captured in the 6th character, E11.319 communicates to payers, registries, and quality programs that this patient has retinopathy without the added visual threat of concurrent macular edema, which carries distinct management implications and a different quality benchmark under MIPS Measure 117.
The ICD-10-CM Official Coding Guidelines (Section I.C.4.a) mandate that a causal relationship between T2DM and retinopathy is assumed unless the provider explicitly documents the retinopathy as unrelated to the diabetes. This means you do not need a linking phrase like “due to” or “secondary to” in the documentation — the co-existence of T2DM and retinopathy is sufficient to report E11.319, and no separate H36.039 (diabetic retinal changes, unspecified) code should be assigned. Coders working inpatient should also check for additional codes such as Z79.4 (long-term insulin use), Z79.84 (oral antidiabetic drugs), or Z79.85 (injectable non-insulin antidiabetic drugs), all of which are required as additional codes when applicable and are frequently missed on inpatient face sheets.
🌳 Code Tree / Hierarchy
E11 Type 2 diabetes mellitus ❌ Non-billable
│
├── E11.0 Type 2 DM with hyperosmolarity ❌ Non-billable
│ ├── E11.00 Without nonketotic hyperglycemic-hyperosmolar coma ✅ Billable
│ └── E11.01 With coma ✅ Billable
│
├── E11.1 Type 2 DM with ketoacidosis ❌ Non-billable
│
├── E11.2 Type 2 DM with kidney complications ❌ Non-billable
│
├── E11.3 Type 2 DM with ophthalmic complications ❌ Non-billable
│ │
│ ├── E11.31 Type 2 DM with unspecified diabetic retinopathy ❌ Non-billable
│ │ ├── E11.311 With macular edema ✅ Billable
│ │ └── E11.319 Without macular edema ◀ THIS CODE ✅ Billable
│ │
│ ├── E11.32 Type 2 DM with mild nonproliferative diabetic retinopathy ❌ Non-billable
│ │ ├── E11.3211 Right eye, with macular edema ✅ Billable
│ │ ├── E11.3212 Left eye, with macular edema ✅ Billable
│ │ ├── E11.3213 Bilateral, with macular edema ✅ Billable
│ │ ├── E11.3219 Unspecified eye, with macular edema ✅ Billable
│ │ ├── E11.3291 Right eye, without macular edema ✅ Billable
│ │ ├── E11.3292 Left eye, without macular edema ✅ Billable
│ │ ├── E11.3293 Bilateral, without macular edema ✅ Billable
│ │ └── E11.3299 Unspecified eye, without macular edema ✅ Billable
│ │
│ ├── E11.33 Type 2 DM with moderate nonproliferative diabetic retinopathy ❌ Non-billable
│ ├── E11.34 Type 2 DM with severe nonproliferative diabetic retinopathy ❌ Non-billable
│ ├── E11.35 Type 2 DM with proliferative diabetic retinopathy ❌ Non-billable
│ └── E11.36 Type 2 DM with diabetic cataract ✅ Billable
│
└── E11.9 Type 2 DM without complications ✅ Billable
Why E11.319 Over E11.311 or Staged Codes Matters for DRG and RA
Using E11.319 when the retinopathy is staged in an attached ophthalmology note is a compliance risk — it under-reports specificity and may suppress quality metrics and risk-adjustment value. Always cross-reference available ophthalmology consult notes before defaulting to the “unspecified” 5th character.
Insulin and Antidiabetic Drug Codes Are Mandatory Additions
The ICD-10-CM tabular instruction at the E11 category header requires an additional code for long-term insulin use (Z79.4), oral antidiabetic/hypoglycemic drugs (Z79.84), or injectable non-insulin antidiabetic drugs (Z79.85) whenever applicable. These are commonly omitted on inpatient claims and can affect medication reconciliation flags during audit.
✅ Includes
- Type 2 DM with documented retinopathy, staging not specified, without macular edema — Used when the provider documents “diabetic retinopathy” without further characterization (nonproliferative vs. proliferative) and the record does not indicate macular edema is present.
- Diabetes NOS with unspecified retinopathy without macular edema — “Diabetes NOS” defaults to E11 (Type 2) per the ICD-10-CM alphabetic index in the absence of documentation specifying another type.
- Insulin-resistant diabetes mellitus with unspecified retinopathy without macular edema — Insulin resistance is an inherent feature of T2DM and is already captured within the E11 category header, requiring no additional code.
- Diabetes due to insulin secretory defect with unspecified retinopathy without macular edema — Beta-cell dysfunction leading to reduced insulin secretion is another pathophysiologic basis subsumed under the E11 block.
- Combination code capturing both T2DM and the ophthalmic complication — Per Section I.C.4.a of the Official Guidelines, no separate retinopathy diagnosis code (e.g., H36.039) should be assigned alongside E11.319.
❌ Excludes
Excludes 1
E08.- — Diabetes mellitus due to underlying condition: This block covers secondary diabetes arising from an identifiable underlying condition such as Cushing’s syndrome or pancreatitis; it is mutually exclusive with E11.- and should never be reported on the same claim. If the provider documents that the patient’s diabetes is caused by a primary disease, E08.- is correct and E11.319 cannot be used simultaneously.
E09.- — Drug or chemical induced diabetes mellitus: When hyperglycemia and retinopathy result from chronic glucocorticoid therapy or another causative agent, E09.- is the correct block; E11.319 is excluded. Coders must query the provider if documentation is ambiguous about whether the diabetes is truly type 2 or drug-induced.
E10.- — Type 1 diabetes mellitus: Type 1 and Type 2 are mutually exclusive classifications; a patient cannot be coded with both E10.- and E11.- for diabetes at the same encounter. If type 1 is documented with retinopathy without macular edema, the parallel code E10.319 applies.
O24.4- — Gestational diabetes mellitus: Gestational diabetes is a distinct entity managed under Chapter 15 (Obstetrics); E11.319 must not be assigned for retinopathy arising in the context of gestational diabetes.
Most Common Excludes 1 Error
The most frequent compliance error is assigning E11.319 alongside E10.- codes when the record is ambiguous about diabetes type — particularly in patients on insulin. Per ICD-10-CM guidelines, insulin use alone does not establish type 1 diabetes; type must be explicitly documented. If type is not specified, default to E11.-, not E10.-.
Excludes 2
Z79.4 — Long-term (current) use of insulin: This code is not excluded from E11.319 — it is listed under Excludes 2 at E11 because insulin use is a separate, additionally reportable status code that may co-exist. Assign Z79.4 as an additional code whenever the patient is documented as currently using insulin for their T2DM management.
Z79.84 / Z79.85 — Long-term use of oral antidiabetic or injectable non-insulin drugs: Similarly, these medication status codes should be assigned in addition to E11.319 when the patient is actively managed with oral hypoglycemics or non-insulin injectables such as GLP-1 receptor agonists; their Excludes 2 listing confirms they are intended to be used together with E11.- codes.
📋 Clinical Overview
Unspecified vs. Staged Diabetic Retinopathy: When Each Code Applies
ICD-10 CM E11.319 is appropriate when the medical record confirms the presence of retinopathy but lacks the ophthalmologic detail needed to assign a staged code. This most often occurs in inpatient medicine, hospitalist, or primary care encounters where the retinopathy is a known secondary diagnosis documented in the problem list but not the focus of the current admission. When ophthalmology consult notes or imaging from the current encounter do stage the retinopathy, coders are obligated to use the more specific code. Failure to use the highest specificity available when the documentation supports it is a compliance deficiency and a missed opportunity for accurate RAF capture.
| Feature | E11.319 | E11.311 | E11.3299 |
|---|---|---|---|
| Retinopathy Stage | Unspecified | Unspecified | Mild nonproliferative, unspecified eye |
| Macular Edema Status | Without | With | Without |
| Laterality Required | No (6-char complete) | No (6-char complete) | No (7-char required for staging, 9 = unspecified eye) |
| HCC Mapping (V28) | HCC 18 | HCC 18 | HCC 18 |
| RAF Impact | Positive | Positive | Positive |
| Typical Setting | Inpatient/hospitalist, primary care | Ophthalmology, retina clinic | Ophthalmology, retina clinic |
| CDI Query Trigger | Retinopathy stage available in consult note | Same | Eye-specific laterality documented but not coded |
CDI Trigger
Any inpatient encounter where the problem list includes “diabetic retinopathy” and an ophthalmology consult or outpatient retinal imaging report from within the past year is available in the chart should trigger a CDI query asking the attending to confirm the current stage and macular edema status. Upgrading from E11.319 to a staged code such as E11.3311 or E11.3411 does not change the DRG family but does enhance risk adjustment capture and payer quality metrics.
Manifestations & Symptom Burden
- Microaneurysms and dot-blot hemorrhages — Early hallmarks of retinal microvascular damage visible on fundoscopy; their presence in a diabetic patient is sufficient to document retinopathy and supports E11.319.
- Blurred or fluctuating vision — A common patient-reported symptom driven by retinal changes and/or co-existing lens changes; does not itself determine the retinopathy stage.
- Decreased visual acuity — When documented in the context of T2DM with retinopathy, H54.7- (unspecified visual loss) codes may be added as additional diagnoses if they represent clinically significant impairment affecting management.
- Hard exudates and cotton-wool spots — Cotton-wool spots specifically signal focal nerve fiber layer ischemia and may indicate progression to moderate or severe NPDR; if present, provider should be queried for staging.
- Floaters or new flashing lights — In established diabetic retinopathy, these symptoms should prompt evaluation for vitreous hemorrhage or tractional retinal detachment, which would require additional diagnosis codes.
Manifestation Coding Rules for Diabetic Eye Complications
Per ICD-10-CM Section I.C.4.a, diabetic retinopathy is a manifestation of T2DM that is subsumed entirely within the E11.3xx combination codes — a separate manifestation code from Chapter 7 (H-codes) is NOT assigned for the retinopathy itself. However, if a separate, distinct ophthalmic condition co-exists (e.g., H26.9 diabetic cataract not already coded as E11.36, or glaucoma), that condition may be reported separately. Always confirm that the additional ophthalmic condition is not already encompassed by the combination code before stacking diagnoses.
💰 HCC Risk Adjustment
| HCC Model | HCC Category | HCC Label | RAF Weight (approximate) | Annual Recapture Required |
|---|---|---|---|---|
| CMS-HCC V28 (2026) | HCC 18 | Diabetes with Ophthalmologic or Unspecified Manifestations | ~0.302 | Yes — every plan year |
| CMS-HCC V24 (legacy) | HCC 18 | Diabetes with Ophthalmologic Manifestations | ~0.302 | Yes |
| RxHCC | Category varies | Diabetes (pharmacy model) | Separate model | Yes |
ICD-10 CM E11.319 maps to HCC 18 under the CMS-HCC V28 model, which CMS fully transitioned to for FY2026 Medicare Advantage plan years. HCC 18 carries a meaningful positive RAF weight (~0.302 in prior model versions), which translates to real premium support dollars for MA plans treating high-complexity diabetic populations. Importantly, CMS dropped E11.9 (T2DM without complications) from V28 risk adjustment entirely, making specificity-coded retinopathy codes like E11.319 even more critical to capture than in prior years. The diagnosis must be documented, assessed, and addressed (or actively managed) in a face-to-face encounter within the plan year to qualify for recapture — a historical claim alone is insufficient. CDI and coding teams should build annual retinopathy query workflows, particularly for Medicare Advantage populations.
🏥 MS-DRG Assignment
| DRG | Description | CC/MCC Requirement |
|---|---|---|
| 637 | Diabetes with MCC | Requires qualifying MCC as secondary diagnosis |
| 638 | Diabetes with CC | Requires qualifying CC as secondary diagnosis |
| 639 | Diabetes without CC/MCC | Default when no CC or MCC is present |
ICD-10 CM E11.319 as a principal inpatient diagnosis routes to the DRG 637-639 diabetes triplet (MDC 10). The default landing without a qualifying secondary CC or MCC diagnosis is DRG 639, the lowest-weighted DRG in the family. DRG weight and expected reimbursement increase significantly with DRG 638 (CC present) or DRG 637 (MCC present), so comprehensive secondary diagnosis capture is the single most impactful coding action in these encounters. Common CCs that coders frequently miss alongside diabetic retinopathy admissions include E11.65 (T2DM with hyperglycemia), I10 (hypertension — note: not a CC alone, but associated combinations can qualify), N18.30-N18.4 (CKD stage 3-4), and E11.40 (T2DM with diabetic neuropathy, unspecified). Always audit the full problem list, nursing notes, and medication administration records to surface secondary diagnoses with CC/MCC potential before finalizing the account.
🔗 Related ICD-10-CM Codes
Diabetic Retinopathy Specificity Upgrades (same body system, higher specificity):
- E11.311 — Type 2 DM with unspecified diabetic retinopathy with macular edema
- E11.3299 — Type 2 DM with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
- E11.3399 — Type 2 DM with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
- E11.3499 — Type 2 DM with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
- E11.3599 — Type 2 DM with proliferative diabetic retinopathy without macular edema, unspecified eye
Related Diabetes and Medication Status Codes (frequently coded with E11.319):
- E11.65 — Type 2 DM with hyperglycemia (common secondary diagnosis; may qualify as CC)
- E11.36 — Type 2 DM with diabetic cataract (separately billable; can be coded with E11.319 if both documented)
- Z79.4 — Long-term (current) use of insulin (required additional code when applicable)
- Z79.84 — Long-term use of oral antidiabetic drugs (required additional code when applicable)
- Z79.85 — Long-term use of injectable non-insulin antidiabetic drugs (required additional code when applicable)
🛠️ Commonly Associated CPT Codes
- 92014 — Ophthalmological services: comprehensive exam, established patient — This is the most frequently used CPT code paired with E11.319 in outpatient ophthalmology and optometry settings for the annual dilated diabetic eye examination; it requires a comprehensive medical eye evaluation with documented anterior and posterior segment findings.
- 92004 — Ophthalmological services: comprehensive exam, new patient — Used when E11.319 is the presenting diagnosis for a new ophthalmology patient being evaluated for the first time for diabetic eye disease; same documentation requirements as 92014 apply.
- 92250 — Fundus photography with interpretation and report (both eyes) — Commonly added on to the ophthalmologic examination to document the retinal appearance at a specific point in time; the photographs serve as baseline documentation supporting the retinopathy diagnosis and are required for MIPS Measure 117 quality reporting.
- 92134 — OCT of the posterior segment (retina) — Optical coherence tomography allows detailed cross-sectional imaging of the macula and retinal layers; when E11.319 is reported, OCT findings of absent macular edema substantiate the “without macular edema” 6th character and provide the imaging basis to choose E11.319 over E11.311.
- 92227 — Remote imaging for detection of retinal disease, unilateral or bilateral — Teleretinal imaging programs used by primary care and endocrinology practices to screen diabetic patients; paired with E11.319 when screening reveals unspecified retinopathy but the image is not ophthalmologist-interpreted in real time.
- 92228 — Remote imaging for monitoring and management of active retinal disease with physician review — Used when a teleretinal platform provides synchronous physician review and interpretation; appropriate companion code to E11.319 in remote diabetic retinopathy monitoring programs.
NCCI Bundling Considerations
92250 (fundus photography) is not bundled with 92014 under NCCI edits and may be reported separately when medically indicated and separately documented. 92134 (OCT retina) is likewise separately billable from the ophthalmologic E/M when distinct clinical necessity is documented — the OCT result must directly inform the clinical decision-making documented in the encounter note. Coders should be aware that 92012 (intermediate established exam) and 92004/92014 (comprehensive exams) cannot be reported on the same date of service by the same provider, as the intermediate service is considered bundled into the comprehensive — this is a frequent audit finding in ophthalmology practices billing E11.319 encounters.
🔬 ICD-10-PCS Crosswalk
ICD-10-PCS does not contain procedure codes specific to diabetic retinopathy diagnosis — the ICD-10-PCS system classifies surgical and therapeutic interventions, not diagnostic confirmation. The following PCS codes represent inpatient procedures that may be performed in the context of diabetic retinal disease:
- 08B53ZZ — Excision of right vitreous, percutaneous approach (vitrectomy, right eye) — Performed when proliferative diabetic retinopathy (a progression beyond unspecified retinopathy) leads to vitreous hemorrhage or tractional retinal detachment requiring surgical intervention; presence of this PCS code alongside E11.319 should trigger a query, as proliferative disease typically warrants a more specific ICD-10-CM retinopathy code.
- 08B63ZZ — Excision of left vitreous, percutaneous approach (vitrectomy, left eye) — Same clinical context as above for the left eye; review whether E11.319 is still appropriate when this procedure is coded.
- 3E0C3GC — Introduction of other therapeutic substance into eye, percutaneous approach — Captures intravitreal injection of pharmacologic agents such as anti-VEGF (bevacizumab, ranibizumab) commonly administered for active diabetic retinal disease; when this PCS code appears, query the ophthalmologist about current retinopathy staging and macular edema status, as anti-VEGF is typically used in proliferative disease or macular edema scenarios rather than stable unspecified retinopathy.
💊 Coding Scenarios and Examples
Scenario 1 — Inpatient Admission for Uncontrolled T2DM, Retinopathy on Problem List A 61-year-old male with T2DM managed on metformin and semaglutide is admitted through the ED for hyperglycemia and dehydration. His problem list includes “diabetic retinopathy” based on a primary care note from 8 months ago, but no ophthalmology consultation is obtained during this admission. There is no documentation of macular edema. The attending’s H&P lists retinopathy as an active chronic condition, managed outpatient.
- Principal Dx: E11.65 (Type 2 DM with hyperglycemia)
- Secondary Dx: E11.319 (Type 2 DM with unspecified diabetic retinopathy without macular edema)
- Additional: Z79.84 (long-term metformin), Z79.85 (long-term semaglutide/GLP-1 injectable)
- Sequencing: E11.65 is the reason for admission and sequences as principal; E11.319 is a secondary chronic condition. Note that bothE11.65 and E11.319 contain the E11 stem — per Official Guidelines, multiple complication codes under E11 may be coded simultaneously as each represents a distinct complication. CDI note: confirm insulin was not used during the admission; if sliding scale insulin was administered, Z79.4 is also required.
Scenario 2 — Outpatient Ophthalmology Visit, Retinopathy Without Macular Edema Confirmed by OCT A 55-year-old female established T2DM patient presents to ophthalmology for annual dilated eye exam. Fundoscopy and OCT confirm the presence of background retinopathy bilaterally without macular edema. The ophthalmologist does not stage the retinopathy beyond “unspecified background retinopathy.”
- Primary Dx: E11.319
- Additional: Z79.84 (oral antidiabetic agent)
- CPT: 92014, 92250, 92134
- Sequencing: E11.319 is the only visit-driving diagnosis. CDI note: the ophthalmologist should be prompted to stage the retinopathy (nonproliferative mild/moderate/severe vs. proliferative) on future visits to enable more specific code assignment and better quality reporting.
Scenario 3 — Inpatient Retinal Consult During Cardiac Admission, Retinopathy Identified as Secondary A 68-year-old male is admitted for NSTEMI. Cardiology requests ophthalmology consult after the patient reports new floaters. The ophthalmology consult note documents “unspecified diabetic retinopathy, no macular edema.” The patient has known T2DM on insulin.
- Principal Dx: I21.4 (NSTEMI) — reason for admission
- Secondary Dx: E11.319, Z79.4 (long-term insulin use)
- DRG driver: I21.4 routes to the AMI DRG family, not DRG 637-639; E11.319 functions as a secondary diagnosis and may qualify as a CC depending on the DRG grouper logic. CDI note: confirm that the consult note explicitly links the retinopathy to T2DM and that the attending co-signs or acknowledges the diagnosis for reportability under UHDDS secondary diagnosis rules.
⚠️ Coding Pitfalls and Tips
-
Defaulting to E11.319 when a staged code is available: The single most common compliance pitfall with this code is using “unspecified” retinopathy when an ophthalmology note within the same encounter or the current plan year documents a specific stage such as moderate NPDR. ICD-10-CM guidelines require coding to the highest degree of specificity supported by the medical record — audit ophthalmology consult notes, discharge summaries, and the outpatient medical record before finalizing E11.319 on any inpatient account.
-
Forgetting required additional medication status codes: The E11 tabular header includes a “Use additional code” instruction for Z79.4, Z79.84, and Z79.85. These are not optional — omitting them when the patient is actively taking insulin or antidiabetic medications is a coding error. Review the MAR and medication reconciliation list on every inpatient account coded with any E11.- code.
-
Assigning a separate H-code for retinopathy alongside E11.319: Never report H36.039 or similar Chapter 7 retinopathy codes alongside E11.319. The combination code architecture of ICD-10-CM is designed so that the diabetic retinopathy is fully captured within E11.319 — adding a separate H-code constitutes duplicate coding and will create claim issues.
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Using E11.319 for type 1 diabetes: Provider documentation must clearly support type 2 diabetes for E11.319 to be assigned. If the record is ambiguous and the patient uses insulin, do not default to type 1 — the ICD-10-CM alphabetic index directs “diabetes NOS” to E11 (Type 2). However, if the provider explicitly states “type 1,” the correct code is E10.319. A query is appropriate when documentation is unclear.
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Missing the HCC capture opportunity during inpatient stays: Many coders treat E11.319 as a “just document it and move on” secondary code on inpatient accounts, but in Medicare Advantage patients, this code contributes to HCC 18 risk adjustment capture. Ensuring it is on every qualifying encounter where the condition is documented, evaluated, and managed — including inpatient stays — is a compliance and revenue integrity responsibility.
-
Incorrectly applying laterality rules: E11.319 has no laterality 7th character because the “unspecified” retinopathy subtype does not carry laterality requirements at this code level. Laterality is required at the E11.32x-E11.35x staging codes. If you attempt to add a 7th character to E11.319, it will produce an invalid code; the code is billable as a complete 6-character code as written.