E11.3213 ICD-10-CM Code: Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
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FY 2026 Apr update / Endocrine, nutritional and metabolic diseases (E00-E89) / Diabetes mellitus (E08-E13)
E11.3213
Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidanceType 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
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 E11.3213 in this effective period.
Excludes 2
OfficialICD-10-CM does not list Excludes 2 notes for E11.3213 in this effective period.
Related Child Codes
Includes
OfficialICD-10-CM does not list Includes notes for E11.3213 in this effective period.
Excludes 1
OfficialICD-10-CM does not list Excludes 1 notes for E11.3213 in this effective period.
Code First
OfficialICD-10-CM does not list Code First sequencing instructions for E11.3213 in this effective period.
Use Additional
OfficialICD-10-CM does not list Use Additional Code instructions for E11.3213 in this effective period.
Code Also
OfficialICD-10-CM does not list Code Also instructions for E11.3213 in this effective period.
Buddy Documentation Tip
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 E11.3213 an HCC code?
Yes. E11.3213 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 E11.3213
For E11.3213to 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 E11.3213 during that encounter, not just copy-forwarded from a problem list.
What This Code Means
E11.3213 is the ICD-10-CM diagnosis code for type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral. E11.3213 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, E11.3213 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.
Type 2 diabetes with mild NPDR with macular edema, bilateral. Requires documentation of bilateral disease at the mild-NPDR severity with macular edema present. Because E11.3213 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 E11.3213 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Type 2 diabetes with mild NPDR with macular edema, bilateral. Requires documentation of bilateral disease at the mild-NPDR severity with macular edema present.
- •Do not default to bilateral if only one eye is documented, E11.3211 (right) or E11.3212 (left) apply. Query the ophthalmology note when laterality is unclear.
- •V28 HCC 37 at RAF 0.302. Bilateral specificity captures the fuller clinical picture.