E08.311
BillableDiabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is E08.311 an HCC code?
Yes. E08.311 maps to Diabetes with Chronic Complications under the V24 model but is not retained in V28.
HCC Category Mapping
RAF weights shown are the community, non-dual, aged base weights from the CMS risk adjustment model file. Actual per-patient RAF contribution depends on member segment, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains in use during the transition and for historical data.
MEAT Criteria for E08.311
For E08.311 to count as a valid HCC diagnosis in a given encounter, the provider's documentation must show MEAT: Monitor, Evaluate, Assess, or Treat. A diagnosis from a prior year does not carry forward automatically — it has to be re-documented and supported each calendar year.
- MMonitor: signs, symptoms, disease progression, or lab trending documented in the note
- EEvaluate: test results, medication response, or physical findings reviewed by the provider
- AAssess: explicit mention in the assessment or plan with acknowledgment of status
- TTreat: medication, referral, procedure, therapy, or counseling tied to the diagnosis
Only one of M/E/A/T is required to support the code, but the documentation must be specific enough to show that the provider actually addressed E08.311 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
E08.311 is the ICD-10-CM diagnosis code for diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema. Eye damage from diabetes caused by an underlying condition with swelling in the macula (center of the retina) affecting vision. E08.311 sits in the ICD-10-CM chapter for endocrine, nutritional and metabolic diseases (e00-e89), within the section covering diabetes mellitus (e08-e13).
Under the older CMS-HCC V24 model, E08.311 maps to Diabetes with Chronic Complications (HCC 18) with a community, non-dual, aged base RAF weight of 0.302. V28 is the CMS-HCC risk adjustment model that reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition.
Confirm macular edema is documented by ophthalmology or eye care provider. Because E08.311 maps to a payment HCC, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's Medicare Advantage risk adjustment score. When documentation is ambiguous, coders should issue a provider query rather than assume the highest-specificity variant.
HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for E08.311 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Confirm macular edema is documented by ophthalmology or eye care provider
- •Code the underlying condition separately; this code requires documentation of unspecified retinopathy with macular involvement
Clinical Significance
Diabetes mellitus due to an underlying condition with unspecified diabetic retinopathy with macular edema indicates diabetic eye disease affecting the macula in a patient with secondary diabetes, but without specification of the retinopathy stage (nonproliferative vs. proliferative). Diabetic macular edema is the leading cause of vision loss in diabetic patients and requires prompt ophthalmologic intervention with anti-VEGF injections, laser photocoagulation, or corticosteroid implants. The presence of macular edema significantly increases the risk of irreversible vision loss.
Documentation Requirements
- ✓Document the underlying condition causing diabetes, the presence of macular edema on dilated fundoscopic examination or optical coherence tomography, laterality (right, left, or bilateral), and the stage of retinopathy if known.
- ✓Query the provider for retinopathy staging (mild/moderate/severe nonproliferative or proliferative) to enable more specific coding.
- ✓Record the treatment plan and visual acuity.
Commonly Confused Codes
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