E13.11 ICD-10-CM Code: Other specified diabetes mellitus with ketoacidosis with coma
E13.11 maps to CMS-HCC V28 36 (RAF 0.166). Documentation must support MEAT. MEAT criteria · RAF calculator · HCC coding software
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FY 2026 Apr update / Endocrine, nutritional and metabolic diseases (E00-E89) / Diabetes mellitus (E08-E13)
E13.11
Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidanceOther specified diabetes mellitus with ketoacidosis with coma
A secondary form of diabetes with dangerous acid buildup in the blood that has progressed to a life-threatening coma.
Buddy Insight
E13.
CMS-HCC V28
MappedHCC 36
RAF 0.166
CMS-HCC V24
MappedHCC 17
RAF 0.302
ACA/HHS
MappedHCC 19
Varies by metal level
ESRD/PACE
MappedHCC 17
RAF 0.084
RXHCC
MappedHCC 30
RAF 0.495
Code Book Path
Inclusion Terms
OfficialICD-10-CM does not list inclusion terms for E13.11 in this effective period.
Excludes 2
OfficialICD-10-CM does not list Excludes 2 notes for E13.11 in this effective period.
Related Child Codes
Includes
OfficialICD-10-CM does not list Includes notes for E13.11 in this effective period.
Excludes 1
OfficialICD-10-CM does not list Excludes 1 notes for E13.11 in this effective period.
Code First
OfficialICD-10-CM does not list Code First sequencing instructions for E13.11 in this effective period.
Use Additional
OfficialICD-10-CM does not list Use Additional Code instructions for E13.11 in this effective period.
Code Also
OfficialICD-10-CM does not list Code Also instructions for E13.11 in this effective period.
Buddy Documentation Tip
MEAT Support
Audit Caution
Common Mistakes
Current with CMS: FY2026 ICD-10-CM Apr 1 update (effective Apr 1 – Sep 30, 2026) · CMS-HCC V28, 100% phased in for payment year 2026. FY2027 code set already staged for October 1, 2026. How HCC Buddy stays current →
Is E13.11 an HCC code?
Yes. E13.11 (Other specified diabetes mellitus with ketoacidosis with coma) maps to Diabetes with Severe Acute Complications under the CMS-HCC V28 risk adjustment model (and Diabetes with Acute Complications under V24), with a community non-dual aged RAF of 0.166. It is billable for payment year 2026.
Coder answer: E13.11 is billable and maps to V28 HCC 36, Diabetes with Severe Acute Complications. Open it in the Code Book for the tabular path, RAF, and MEAT checklist.
- Code
- E13.11
- Description
- Other specified diabetes mellitus with ketoacidosis with coma
- HCC (V28)
- HCC 36 — Diabetes with Severe Acute Complications
- RAF
- 0.166
- Billable
- Yes
- Payment year
- 2026
HCC Category Mapping
Each model's RAF is its CMS base weight for that model's standard population, so weights are not directly comparable across models: CMS-HCC V28 and V24 use Community, Non-Dual, Aged; ESRD uses the dialysis continuing-enrollee model; RxHCC is the Part D continuing-enrollee, non-low-income, aged weight (a larger scale than CMS-HCC). ACA/HHS has no single weight — it varies by metal level. 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.
Work E13.11 in the Code Book — tabular path, V28 RAF, and MEAT checklist →
MEAT Criteria for E13.11
For E13.11 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 E13.11 during that encounter, not just copy-forwarded from a problem list.
Coder workflow notes
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What This Code Means
E13.11 is the ICD-10-CM diagnosis code for other specified diabetes mellitus with ketoacidosis with coma. A secondary form of diabetes with dangerous acid buildup in the blood that has progressed to a life-threatening coma. E13.11 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, E13.11 maps to Diabetes with Severe Acute Complications (HCC 36) with a community, non-dual, aged base RAF weight of 0.166. Under the older CMS-HCC V24 model, E13.11 maps to Diabetes with Acute Complications (HCC 17) 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.
Ketoacidosis with coma is a medical emergency; verify both ketoacidosis and coma are documented. Because E13.11 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 E13.11 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Ketoacidosis with coma is a medical emergency; verify both ketoacidosis and coma are documented
- •Document the underlying cause of the secondary diabetes (E13) in addition to this complication code
Clinical Significance
E13.11 represents the most critical presentation of diabetic ketoacidosis in other specified diabetes, with progression to coma. This is a life-threatening emergency requiring immediate intensive care with mechanical ventilation support, continuous insulin infusion, aggressive hydration, and careful correction of severe metabolic acidosis and electrolyte imbalances.
Documentation Requirements
- ✓The provider must document secondary diabetes type with the underlying etiology, presence of ketoacidosis with supporting laboratory evidence (acidotic pH, elevated ketones, hyperglycemia), and confirmed coma or profound alteration in consciousness directly attributable to the metabolic crisis.