E13.11
BillableOther specified diabetes mellitus with ketoacidosis with coma
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is E13.11 an HCC code?
Yes. E13.11 maps to Diabetes with Severe Acute Complications under the CMS-HCC V28 risk adjustment model (and Diabetes with Acute 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 E13.11
For E13.11to 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.
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.