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E13.3411 ICD-10-CM Code: Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye

Billing Status: YES. This is a valid, specific, and billable ICD-10-CM reference.

Inpatient Payment Groups (MS-DRG)

MS-DRGs this diagnosis helps define, as principal or secondary, per the CMS ICD-10-CM/PCS MS-DRG Definitions Manual v43.0, Appendix B.

  • MS-DRG 008 — SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT (MDC PRE)
  • MS-DRG 010 — PANCREAS TRANSPLANT (MDC PRE)
  • MS-DRG 019 — SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS (MDC PRE)
  • MS-DRG 124 — OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT (MDC 02)
  • MS-DRG 125 — OTHER DISORDERS OF THE EYE WITHOUT MCC (MDC 02)

A diagnosis appearing in a group's logic does not by itself determine the DRG assigned to a stay; the grouper uses the full claim.

Risk Adjustment (CMS-HCC)

Payment categories this diagnosis maps to under CMS-HCC V28, payment year 2026.

  • HCC 298 — Severe Diabetic Eye Disease, Retinal Vein Occlusion, and Vitreous Hemorrhage
  • HCC 37 — Diabetes with Chronic Complications (supersedes HCC 38)

Other models: CMS-HCC V22 HCC 18 · RxHCC V08 HCC 30

Risk scores depend on the enrollee's full accepted diagnosis set and segment; a category mapping alone does not determine payment.

Official Registry Overview & Definition

Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye is a billable ICD-10-CM diagnosis code (E13.3411).

Official Tabular Instructional Notes

Sequencing, inclusion, and exclusion notes published for E13.3411 in the official ICD-10-CM tabular list.

Includes

Conditions the official ICD-10-CM tabular list includes under this code.

  • diabetes mellitus due to genetic defects of beta-cell function
  • diabetes mellitus due to genetic defects in insulin action
  • postpancreatectomy diabetes mellitus
  • postprocedural diabetes mellitus
  • secondary diabetes mellitus NEC

Excludes1 — Not Coded Here

Conditions generally not reported together with this code (Excludes1) -- an error unless the two conditions are documented as unrelated to each other (ICD-10-CM Official Guidelines, Section I.A.12.a).

Use Additional Code

Supplementary codes the tabular list directs you to add.

  • Use additional code to identify control using:
  • injectable non-insulin antidiabetic drugs (Z79.85)
  • insulin (Z79.4)
  • oral antidiabetic drugs (Z79.84)
  • oral hypoglycemic drugs (Z79.84)

Frequently Compared Codes

The official Excludes notes on E13.3411 name these codes. Each comparison page covers when the two can — or must not — be reported together.

Change history

  • FY2017 — 2016-10-01
    Added to the code set
    Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
    FY2017 changes

Verify Before Coding

  • No Medicare Code Editor or MS-DRG Definitions Manual restrictions apply to this code.

From the code registry, the Medicare Code Editor, and the MS-DRG Definitions Manual. Check it against a full claim.

Relationships & Classification

Other codes that name E13.3411 or its code family, from the CMS ICD-10-CM tabular instructional notes. Tabular-note edges are stored at the code family level that carries each note.

5 Excludes1 notes across 2 chapters: E08 (via E13.-), E09 (via E13.-), E10 (via E13.-), E11 (via E13.-), H36 (via E13.3.-).

1 Code First instructions: E89.1 (via E13.-).

1 Use Additional Code instructions: Z90.41 (via E13.-).

Potential MS-DRG Relationships (FY2026)

Not on the CMS CC/MCC list — as a secondary diagnosis this code does not change MS-DRG severity.

Named in the grouper logic of 5 MS-DRGs: DRG 008 (MDC PRE), DRG 010 (MDC PRE), DRG 019 (MDC PRE), DRG 124 (MDC 02), DRG 125 (MDC 02).

From the CMS MS-DRG Definitions Manual (Appendices B and C). Actual DRG assignment depends on the complete claim.

Clinical classification (AHRQ CCSR):END003 — Diabetes mellitus with complication (default); END006 — Diabetes mellitus, due to underlying condition, drug or chemical induced, or other specified type; EYE005 — Retinal and vitreous conditions.

Clinical Classifications Software Refined (CCSR) for ICD-10-CM Diagnoses. Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality.

Related Codes

Same condition, opposite side

Same category and title, differing only in which side of the body is affected.

E13.3412 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye (left), E13.3419 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye (unspecified)

Same CMS-HCC risk category (V28)

CMS maps these diagnoses to the same Hierarchical Condition Categories (Severe Diabetic Eye Disease, Retinal Vein Occlusion, and Vitreous Hemorrhage, Diabetes with Chronic Complications) for risk-adjusted payment.

E13.3319 — Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye (Diabetes with Chronic Complications), E13.3391 — Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye (Diabetes with Chronic Complications), E13.3392 — Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye (Diabetes with Chronic Complications), E13.3393 — Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral (Diabetes with Chronic Complications), E13.3399 — Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye (Diabetes with Chronic Complications), E13.3412 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye (Diabetes with Chronic Complications), E13.3413 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral (Diabetes with Chronic Complications), E13.3419 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye (Diabetes with Chronic Complications), E13.3491 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye (Diabetes with Chronic Complications), E13.3492 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye (Diabetes with Chronic Complications), +329 more

Related risk categories

These categories interact through CMS's HCC hierarchy — one can suppress the other's risk-adjustment weight when both are present on a claim.

Diabetes with Severe Acute Complications (related risk category), Pancreas Transplant Status (related risk category), Diabetes with Glycemic, Unspecified, or No Complications (related risk category)

Same clinical category (CCSR)

AHRQ's Clinical Classifications Software groups these diagnoses under the same clinical categories (Diabetes mellitus with complication, Diabetes mellitus, due to underlying condition, drug or chemical induced, or other specified type, Retinal and vitreous conditions).

E13.3391 — Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye, E13.3392 — Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye, E13.3393 — Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral, E13.3399 — Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye, E13.341 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, E13.3412 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye, E13.3413 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral, E13.3419 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye, E13.349 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, E13.3491 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye, +913 more

Lab tests where this diagnosis supports Medicare coverage

Medicare's National Coverage Determinations list this diagnosis as medical justification for these lab tests.

HbA1c Test (Glycated Hemoglobin) (lab test), Blood Glucose Test (lab test), Gamma-glutamyl Transferase (GGT) Test (lab test), Iron Panel (lab test), Lipid Panel (lab test), Thyroid Stimulating Hormone (TSH) (lab test)

Contextual Map

Every relationship of E13.3411 in one view: hierarchy, official tabular instructions in both directions, clinical classification, risk adjustment, MS-DRG participation, index terms and change history — each edge carrying the CMS source it derives from.

Hierarchy

  • E00-E89 — Chapter 4: Endocrine, Nutritional and Metabolic Diseases (E00-E89) (E00-E89) [Hierarchy]
  • E08-E13 — Diabetes mellitus [Hierarchy]

Referenced by Excludes1 notes

  • E08 — Diabetes mellitus due to underlying condition [Excludes1](via E13.-): “postpancreatectomy diabetes mellitus (E13.-)” · check together
  • E09 — Drug or chemical induced diabetes mellitus [Excludes1](via E13.-): “postpancreatectomy diabetes mellitus (E13.-)” · check together
  • E10 — Type 1 diabetes mellitus [Excludes1](via E13.-): “postpancreatectomy diabetes mellitus (E13.-)” · check together
  • E11 — Type 2 diabetes mellitus [Excludes1](via E13.-): “postpancreatectomy diabetes mellitus (E13.-)” · check together
  • H36 — Retinal disorders in diseases classified elsewhere [Excludes1](via E13.3.-): “diabetic retinopathy (E08.3-, E09.3-, E10.3-, E11.3-, E13.3-)” · check together

Referenced by Code First instructions

  • E89.1 — Postprocedural hypoinsulinemia [Code First](via E13.-): “, if applicable, diabetes mellitus (postpancreatectomy) (postprocedural) (E13.-)” · check together

Referenced by Use Additional Code instructions

  • Z90.41 — Acquired absence of pancreas [Use Additional Code](via E13.-): “diabetes mellitus, postpancreatectomy (E13.-)” · check together

Clinical classification (CCSR)

  • END003 — Diabetes mellitus with complication [CCSR]
  • END006 — Diabetes mellitus, due to underlying condition, drug or chemical induced, or other specified type [CCSR]
  • EYE005 — Retinal and vitreous conditions [CCSR]

Risk adjustment (CMS-HCC)

  • HCC 298 — Severe Diabetic Eye Disease, Retinal Vein Occlusion, and Vitreous Hemorrhage [CMS-HCC]
  • HCC 37 — Diabetes with Chronic Complications [CMS-HCC]: “Diabetes with Chronic Complications — supersedes HCC 38 (Diabetes with Glycemic, Unspecified, or No Complications)”

Potential MS-DRG

  • DRG 008 — SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT [MS-DRG]: “SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT (MDC PRE)”
  • DRG 010 — PANCREAS TRANSPLANT [MS-DRG]: “PANCREAS TRANSPLANT (MDC PRE)”
  • DRG 019 — SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS [MS-DRG]: “SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS (MDC PRE)”
  • DRG 124 — OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT [MS-DRG]: “OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT (MDC 02)”
  • DRG 125 — OTHER DISORDERS OF THE EYE WITHOUT MCC [MS-DRG]: “OTHER DISORDERS OF THE EYE WITHOUT MCC (MDC 02)”

MDC crossing · procedures (1353)

  • Pre-MDC[MDC crossing]: “Pre-MDC — the grouper's crossing between diagnoses and procedures: a principal diagnosis sets the MDC, and same-MDC procedures move the stay to its surgical DRGs.”
  • MDC 02 — Diseases and Disorders of the Eye [MDC crossing]: “Diseases and Disorders of the Eye — the grouper's crossing between diagnoses and procedures: a principal diagnosis sets the MDC, and same-MDC procedures move the stay to its surgical DRGs.”
  • 02HA0QZ — Insertion of Implantable Heart Assist System into Heart, Open Approach [Same-MDC procedure]: “Insertion of Implantable Heart Assist System into Heart, Open Approach — grouped in MDC PRE, the procedure side of this code's crossing.” · check together
  • 02HA0RZ — Insertion of Short-term External Heart Assist System into Heart, Open Approach [Same-MDC procedure]: “Insertion of Short-term External Heart Assist System into Heart, Open Approach — grouped in MDC PRE, the procedure side of this code's crossing.” · check together
  • 02HA3QZ — Insertion of Implantable Heart Assist System into Heart, Percutaneous Approach [Same-MDC procedure]: “Insertion of Implantable Heart Assist System into Heart, Percutaneous Approach — grouped in MDC PRE, the procedure side of this code's crossing.” · check together
  • 02HA4QZ — Insertion of Implantable Heart Assist System into Heart, Percutaneous Endoscopic Approach [Same-MDC procedure]: “Insertion of Implantable Heart Assist System into Heart, Percutaneous Endoscopic Approach — grouped in MDC PRE, the procedure side of this code's crossing.” · check together
  • 02RA0LZ — Replacement of Heart with Biologic and Synthetic Substitute, Autoregulated Electrohydraulic, Open Approach [Same-MDC procedure]: “Replacement of Heart with Biologic and Synthetic Substitute, Autoregulated Electrohydraulic, Open Approach — grouped in MDC PRE, the procedure side of this code's crossing.” · check together
  • and 1348 more

Nearest codes (40)

  • E13 — Other specified diabetes mellitus [Sibling]
  • E13.3213 — Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral [Sibling]
  • E13.3219 — Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye [Sibling]
  • E13.329 — Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema [Sibling]
  • E13.3291 — Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye [Sibling]
  • E13.3292 — Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye [Sibling]
  • E13.3293 — Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral [Sibling]
  • E13.3299 — Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye [Sibling]
  • and 32 more

Change history

  • FY2017 — Added to the code set [Change history]

Frequently Asked Questions (FAQ) & Clinical Guidance

Does E13.3411 require a 7th character?

Yes. One of the following 7th characters is to be assigned to codes in subcategory E13.34 to designate laterality of the disease:.

Nearest Codes in This Family

Official ICD-10-CM classifications closest to E13.3411 in its code family, with their registry titles.

  • E13.3392 — Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
  • E13.3393 — Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
  • E13.3399 — Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
  • E13.34 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy
  • E13.341 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
  • E13.3412 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
  • E13.3413 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
  • E13.3419 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye
  • E13.349 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema
  • E13.3491 — Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye

View all codes in the E13 family