How Do I Code Diabetes With Retinopathy? Severity, Macular Edema, and Laterality

Section I.C.4.a makes every diabetes code a combination code — type of diabetes, body system, complication — and the ophthalmic subcategory takes that further than any other: E11.32 through E11.35 add a 6th character for macular edema and a 7th character for laterality. The tabular note under each of them reads: “One of the following 7th characters is to be assigned to codes in subcategory E11.3- to designate laterality of the disease: 1 right eye, 2 left eye, 3 bilateral, 9 unspecified eye.” The 7th character is required for the code to be valid (Section I.A.5), and Section I.B.13’s laterality rules apply: bilateral when both eyes are affected, unspecified eye rarely.

The Index route “Diabetes › type 2 › with › retinopathy” lands on E11.319, unspecified retinopathy without macular edema — the default when the record says only “diabetic retinopathy.” The unspecified subcategory E11.31 has no 7th character; the typed subcategories do.

1. Type of retinopathy, as documented: unspecified (E11.31), mild nonproliferative (E11.32), moderate (E11.33), severe (E11.34), proliferative (E11.35). The subcategories follow the tabular’s own order; the record’s wording picks one.
2. Macular edema: 6th character 1 with, 9 without (E11.311 / E11.319; E11.3211 / E11.3291, and so on).
3. Eye, for E11.32–E11.35: 7th character 1, 2, 3 or 9. Both eyes documented is 3 — one code, not two.
4. Macular edema that has resolved after treatment is its own code, E11.37, with a placeholder X and the same 7th-character set: E11.37X9 for unspecified eye.
5. Other ophthalmic complications: E11.36 diabetic cataract (no laterality); E11.39 other, with a Use Additional Code note for the manifestation such as diabetic glaucoma (H40–H42).
6. Add the Z79 control-agent code and any other complication codes — as many E11 codes as the documentation supports (I.C.4.a).

1. “Type 2 diabetes with diabetic retinopathy,” nothing more.E11.319 — unspecified type, no macular edema documented, and E11.31 takes no laterality character.
2. Type 2 diabetes with mild nonproliferative retinopathy and macular edema, right eye.E11.3211: mild NPDR (32), with edema (1), right eye (1).
3. Proliferative retinopathy without macular edema in both eyes.E11.3593: proliferative (35), without edema (9), bilateral (3) — one code for both eyes, per Section I.B.13.
4. Macular edema in the left eye treated and documented as resolved; retinopathy no longer described.E11.37X2, with the placeholder X in the 6th position and 2 for the left eye.

• Dropping the 7th character on E11.32–E11.35 — the code is invalid without it.
• Adding a 7th character to E11.31 — the unspecified subcategory has none.
• Reporting right and left codes when both eyes are affected — 7th character 3 is the bilateral code.
• Coding “diabetic retinopathy” to a typed subcategory the record does not support — unspecified type is E11.31.
• Reporting a separate H35 retinopathy code beside the E11.3- code — the combination code already classifies the retinopathy.
• Omitting the X in E11.37 — the placeholder is part of the code.

• The retinopathy type — mild, moderate or severe nonproliferative, or proliferative — from the provider.
• Whether macular edema is present, or documented as resolved after treatment (E11.37).
• The eye or eyes affected; if not stated by the provider, another clinician’s documentation may supply it, and unspecified eye is a last resort (I.B.13).
• Other ophthalmic diagnoses — cataract (E11.36) or glaucoma (E11.39 plus the H40–H42 code) — each takes its own combination code.