E10.319
BillableType 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is E10.319 an HCC code?
Yes. E10.319 maps to Diabetes with Chronic Complications under the CMS-HCC V28 risk adjustment model (and Diabetes with Chronic Complications under V24).
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 E10.319
For E10.319 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 E10.319 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
E10.319 is the ICD-10-CM diagnosis code for type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema. Type 1 diabetes with retinal damage from diabetes without swelling in the macula, affecting peripheral or general retinal function. E10.319 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 CMS-HCC V28 risk adjustment model, E10.319 maps to Diabetes with Chronic Complications (HCC 37) with a community, non-dual, aged base RAF weight of 0.245. Under the older V24 model, E10.319 mapped to the same category but with a base RAF weight of 0.302 — V28 recalibrated weights across the entire model. 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 documentation explicitly states absence of macular edema. Because E10.319 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 E10.319 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Confirm documentation explicitly states absence of macular edema
- •This represents unspecified retinopathy severity without the more serious macular complication
Clinical Significance
Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema indicates retinal damage from Type 1 diabetes that has not been staged but does not involve macular fluid accumulation. While less immediately vision-threatening than cases with macular edema, any retinopathy signals ongoing microvascular damage and the need for regular ophthalmologic surveillance. Progression to proliferative retinopathy with neovascularization remains a risk requiring monitoring.
Documentation Requirements
- ✓Type 1 diabetes and retinopathy must be documented with ophthalmologic examination findings.
- ✓The absence of macular edema should be confirmed.
- ✓The provider should be queried to specify retinopathy severity (nonproliferative mild/moderate/severe or proliferative) when possible.
- ✓Visual acuity and fundoscopic examination findings should be included.