E13.3519 ICD-10-CM Code: Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye
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FY 2026 Apr update / Endocrine, nutritional and metabolic diseases (E00-E89) / Diabetes mellitus (E08-E13)
E13.3519
Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidanceOther specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye
Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye
CMS-HCC V28
00
RAF 0
CMS-HCC V24
00
RAF 0
ACA/HHS
00
RAF 0
ESRD/PACE
00
RAF 0
RXHCC
MappedHCC 30
RAF 0.0
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Code Book Path
Inclusion Terms
OfficialICD-10-CM does not list inclusion terms for E13.3519 in this effective period.
Excludes 2
OfficialICD-10-CM does not list Excludes 2 notes for E13.3519 in this effective period.
Related Child Codes
Includes
OfficialICD-10-CM does not list Includes notes for E13.3519 in this effective period.
Excludes 1
OfficialICD-10-CM does not list Excludes 1 notes for E13.3519 in this effective period.
Code First
OfficialICD-10-CM does not list Code First sequencing instructions for E13.3519 in this effective period.
Use Additional
OfficialICD-10-CM does not list Use Additional Code instructions for E13.3519 in this effective period.
Code Also
OfficialICD-10-CM does not list Code Also instructions for E13.3519 in this effective period.
Last updated: FY2026 ICD-10-CM Apr update, Apr 1, 2026 through Sep 30, 2026. CMS-HCC V28 is 100% phased in for payment year 2026.
Is E13.3519 an HCC code?
No. E13.3519 is a billable ICD-10-CM code but does not map to any HCC category in V28, V24, ESRD, or RxHCC.
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 E13.3519
For E13.3519to 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 E13.3519 during that encounter, not just copy-forwarded from a problem list.
What This Code Means
E13.3519 is the ICD-10-CM diagnosis code for other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye. E13.3519 sits in the ICD-10-CM chapter for endocrine, nutritional and metabolic diseases (e00-e89), within the section covering diabetes mellitus (e08-e13).
E13.3519 is a billable ICD-10-CM code but does not map to a payment HCC under the CMS-HCC V28, V24, ESRD, or RxHCC risk adjustment models. It can be reported on Medicare Advantage encounter data submissions but it does not contribute to a beneficiary's RAF score and therefore does not affect risk-adjusted payments to the plan.
E13.3519 is a billable ICD-10-CM code that can be reported on claims but does not currently contribute to a Medicare Advantage member's RAF score under any CMS risk adjustment model (V28, V24, ESRD, or RxHCC). Coders reviewing E13.3519 should check whether additional documentation would support a more specific child code in the same hierarchy that does map to a payment HCC, capturing the correct specificity is the highest-impact RAF improvement available within accurate coding.
HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for E13.3519 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.