E11.311
BillableType 2 diabetes mellitus 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 E11.311 an HCC code?
Yes. E11.311 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 E11.311
For E11.311 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 E11.311 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
E11.311 is the ICD-10-CM diagnosis code for type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema. Type 2 diabetes that has caused damage to the blood vessels in the eye (retinopathy) with swelling in the macula, the part of the eye responsible for detailed vision. E11.311 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, E11.311 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.
Macular edema indicates fluid accumulation in the macula; ensure this is specifically documented. Because E11.311 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 E11.311 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Macular edema indicates fluid accumulation in the macula; ensure this is specifically documented
- •The code specifies 'unspecified' retinopathy, meaning the type or stage is not further specified
Clinical Significance
Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema indicates diabetes-related retinal damage with fluid accumulation in the macula, the area of the retina responsible for central visual acuity. Macular edema is the most common cause of vision loss in diabetic patients and requires prompt treatment with anti-VEGF injections, laser photocoagulation, or corticosteroid therapy to prevent permanent vision impairment.
Documentation Requirements
- ✓Documentation must confirm diabetic retinopathy with macular edema in a Type 2 diabetic patient.
- ✓Ophthalmological examination findings including optical coherence tomography showing macular thickening, fundoscopic examination results, and visual acuity measurements should be recorded.
- ✓The laterality (right, left, bilateral) should be specified.
- ✓The retinopathy should be further classified as mild, moderate, severe nonproliferative, or proliferative when possible.
Commonly Confused Codes
- •E11.319 (retinopathy without macular edema) is used when the macula is not involved.
- •E11.3211-E11.3599 (specific stages of retinopathy) provide greater specificity about the retinopathy type and should be used when documented.
- •E11.36 (diabetic cataract) covers lens opacity rather than retinal disease.
- •H35.81 (retinal edema) should not be used instead of this combination code.