E13.311
BillableOther specified diabetes mellitus with unspecified diabetic retinopathy with macular edema
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is E13.311 an HCC code?
Yes. E13.311 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 E13.311
For E13.311 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 E13.311 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
E13.311 is the ICD-10-CM diagnosis code for other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema. A secondary form of diabetes that has damaged the blood vessels in the eye, causing swelling in the macula (central vision area). E13.311 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, E13.311 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.
Macular edema is a serious complication affecting vision; verify ophthalmology documentation confirms this finding. Because E13.311 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 E13.311 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Macular edema is a serious complication affecting vision; verify ophthalmology documentation confirms this finding
- •The fifth character '1' indicates macular edema is present; use E13.319 if macular edema is absent
Clinical Significance
E13.311 identifies unspecified diabetic retinopathy with macular edema in other specified diabetes. Macular edema represents fluid accumulation in the macula causing central vision impairment and is one of the leading causes of vision loss in diabetic patients. The 'unspecified' designation indicates the retinopathy stage (mild, moderate, severe, or proliferative) has not been documented.
Documentation Requirements
- ✓Documentation must confirm secondary diabetes, the presence of retinopathy, and macular edema as verified by ophthalmologic examination or retinal imaging.
- ✓The provider should be queried to specify the retinopathy stage (nonproliferative mild/moderate/severe or proliferative) to allow for more specific code assignment.