E13.319
BillableOther specified diabetes mellitus with unspecified diabetic retinopathy without macular edema
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is E13.319 an HCC code?
Yes. E13.319 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 E13.319
For E13.319 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 E13.319 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
E13.319 is the ICD-10-CM diagnosis code for other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema. A secondary form of diabetes that has damaged the blood vessels in the eye, but without swelling in the macula. E13.319 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, E13.319 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, E13.319 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.
This code indicates diabetic retinopathy without macular edema; confirm imaging or ophthalmology findings. Because E13.319 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 E13.319 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •This code indicates diabetic retinopathy without macular edema; confirm imaging or ophthalmology findings
- •The fifth character '9' indicates no macular edema; use E13.311 if macular edema is documented
Clinical Significance
E13.319 captures unspecified diabetic retinopathy without macular edema in other specified diabetes mellitus. The absence of macular edema indicates the central retina is not currently affected by fluid accumulation, though the patient still has retinal vascular damage requiring ongoing ophthalmologic surveillance to prevent progression.
Documentation Requirements
- ✓The record must document secondary diabetes with retinopathy confirmed by ophthalmologic examination.
- ✓The absence of macular edema should be stated or implied by imaging findings.
- ✓Providers should be queried to specify the retinopathy stage for more accurate coding.