E09.311 ICD-10-CM Code: Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
HCC Buddy Code Card
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FY 2026 Apr update / Endocrine, nutritional and metabolic diseases (E00-E89) / Diabetes mellitus (E08-E13)
E09.311
Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidanceDrug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
Diabetes caused by medications or chemicals with eye damage (retinopathy) of unspecified type that includes swelling in the macula (central vision area).
Buddy Insight
Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema represents drug-induced diabetes that has caused retinal damage with fluid accumulation in the macula, the area responsible for central vision.
CMS-HCC V28
00
RAF 0
CMS-HCC V24
MappedHCC 18
RAF 0.302
ACA/HHS
00
RAF 0
ESRD/PACE
MappedHCC 18
RAF 0.0
RXHCC
MappedHCC 30
RAF 0.0
Code Trumping
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Code Book Path
Inclusion Terms
OfficialICD-10-CM does not list inclusion terms for E09.311 in this effective period.
Excludes 2
OfficialICD-10-CM does not list Excludes 2 notes for E09.311 in this effective period.
Related Child Codes
Includes
OfficialICD-10-CM does not list Includes notes for E09.311 in this effective period.
Excludes 1
OfficialICD-10-CM does not list Excludes 1 notes for E09.311 in this effective period.
Code First
OfficialICD-10-CM does not list Code First sequencing instructions for E09.311 in this effective period.
Use Additional
OfficialICD-10-CM does not list Use Additional Code instructions for E09.311 in this effective period.
Code Also
OfficialICD-10-CM does not list Code Also instructions for E09.311 in this effective period.
Buddy Documentation Tip
MEAT Support
Audit Caution
Common Mistakes
Last updated: FY2026 ICD-10-CM Apr update, Apr 1, 2026 through Sep 30, 2026. CMS-HCC V28 is 100% phased in for payment year 2026.
Is E09.311 an HCC code?
Yes. E09.311 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 E09.311
For E09.311to 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 E09.311 during that encounter, not just copy-forwarded from a problem list.
What This Code Means
E09.311 is the ICD-10-CM diagnosis code for drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema. Diabetes caused by medications or chemicals with eye damage (retinopathy) of unspecified type that includes swelling in the macula (central vision area). E09.311 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, E09.311 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 with provider whether the retinopathy type is truly unspecified or if it can be more specifically classified. Because E09.311 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 E09.311 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Confirm with provider whether the retinopathy type is truly unspecified or if it can be more specifically classified
- •The presence of macular edema indicates more advanced eye disease requiring close monitoring
Clinical Significance
Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema represents drug-induced diabetes that has caused retinal damage with fluid accumulation in the macula, the area responsible for central vision. Macular edema is a vision-threatening complication that may require anti-VEGF injections, laser treatment, or corticosteroid therapy. The 'unspecified' retinopathy designation indicates the severity stage (nonproliferative vs. proliferative) has not been documented.
Documentation Requirements
- ✓The causative drug or chemical must be identified.
- ✓Ophthalmologic examination findings should document the presence of macular edema with optical coherence tomography or fluorescein angiography results.
- ✓The provider should specify the retinopathy stage (mild/moderate/severe nonproliferative or proliferative) to allow more specific code selection.
- ✓Laterality should also be documented.
Commonly Confused Codes
- •E09.319 (unspecified retinopathy without macular edema) is used when macular edema is absent.
- •More specific retinopathy codes (E09.321x-E09.359x) should be used when the stage of retinopathy is documented.
- •E11.311 (Type 2 with unspecified retinopathy with macular edema) is incorrect for drug-induced diabetes.