E11.3491 ICD-10-CM Code: Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
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FY 2026 Apr update / Endocrine, nutritional and metabolic diseases (E00-E89) / Diabetes mellitus (E08-E13)
E11.3491
Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidanceType 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
CMS-HCC V28
MappedHCC 37
RAF 0.245
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 E11.3491 in this effective period.
Excludes 2
OfficialICD-10-CM does not list Excludes 2 notes for E11.3491 in this effective period.
Related Child Codes
Includes
OfficialICD-10-CM does not list Includes notes for E11.3491 in this effective period.
Excludes 1
OfficialICD-10-CM does not list Excludes 1 notes for E11.3491 in this effective period.
Code First
OfficialICD-10-CM does not list Code First sequencing instructions for E11.3491 in this effective period.
Use Additional
OfficialICD-10-CM does not list Use Additional Code instructions for E11.3491 in this effective period.
Code Also
OfficialICD-10-CM does not list Code Also instructions for E11.3491 in this effective period.
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 E11.3491 an HCC code?
Yes. E11.3491 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 E11.3491
For E11.3491to 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 E11.3491 during that encounter, not just copy-forwarded from a problem list.
What This Code Means
E11.3491 is the ICD-10-CM diagnosis code for type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye. E11.3491 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, E11.3491 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, E11.3491 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.
Coders should report E11.3491 only when the provider documentation supports the specific condition described, since more specific codes within the same hierarchy can capture additional clinical detail and may carry a higher RAF weight. Because E11.3491 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 E11.3491 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.