E11.36
BillableType 2 diabetes mellitus with diabetic cataract
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is E11.36 an HCC code?
Yes. E11.36 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 E11.36
For E11.36 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 E11.36 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
E11.36 is the ICD-10-CM diagnosis code for type 2 diabetes mellitus with diabetic cataract. Type 2 diabetes that has caused clouding of the eye lens (cataract), leading to blurred or dimmed vision. E11.36 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, E11.36 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, E11.36 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.
Diabetic cataracts may develop earlier and progress faster than age-related cataracts. Because E11.36 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 E11.36 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Diabetic cataracts may develop earlier and progress faster than age-related cataracts
- •Document whether the cataract is unilateral or bilateral for complete clinical documentation
Clinical Significance
Type 2 diabetes mellitus with diabetic cataract reflects lens opacity caused by osmotic and metabolic changes from chronic hyperglycemia. Diabetic cataracts develop earlier and progress more rapidly than age-related cataracts, with the osmotic stress from sorbitol accumulation in the lens being a key pathogenic mechanism. These cataracts can significantly impair vision and may complicate diabetic retinopathy monitoring by obscuring fundoscopic examination.
Documentation Requirements
- ✓The provider must document cataract formation as a complication of Type 2 diabetes, distinguishing it from age-related or other causes of cataract.
- ✓Ophthalmological examination findings including cataract type (posterior subcapsular is most common in diabetes), visual acuity impact, and surgical planning should be recorded.
- ✓Laterality should be specified.
Commonly Confused Codes
- •H25 series (age-related cataract) is used for cataracts not attributable to diabetes.
- •H26.9 (unspecified cataract) does not capture the diabetic relationship.
- •E11.311/E11.319 (diabetic retinopathy) cover retinal disease rather than lens opacity.
- •E11.39 (other ophthalmic complication) should not be used when cataract is specifically documented.