2027 ICD-10-CM Diagnosis Code E11.3531Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
ICD-10-CM Codes›E00–E89›E08-E13›E11
- Billable — Valid for Submission
- Risk Adjusts — HCC 37
- 7th Character 1 — Right Eye
- Chronic Condition
E11.3531 is a billable ICD-10-CM diagnosis code for type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye. The 7th character 1 means right eye. It is valid on HIPAA claims for fiscal year 2027 (October 1, 2026 through September 30, 2027) and groups to MS-DRG 8, 10, 19, 124 through 125. In AHRQ's Clinical Classifications Software (CCSR), this diagnosis falls under Diabetes mellitus with complication; Diabetes mellitus, Type 2; and Retinal and vitreous conditions.
For Medicare Advantage risk adjustment, E11.3531 maps to CMS-HCC Category 37 (Diabetes with Chronic Complications) under the V28 model, adding a risk factor of about 0.166 for a community, non-dual, aged beneficiary in payment year 2027.
This medical diagnosis code is frequently used in Family Practice medical specialties to designate conditions such diabetes mellitus with complications type 2.
Code Identity
Code Classification
Quality Payment Program MeasuresBilling
Medicare quality measures that can apply when E11.3531 is part of the patient record.
Diabetes: Glycemic Status Assessment Greater Than 9%
High Priority: YES
Measure Type: Intermediateoutcome
Submission Methods: Claims, Electronic Health Record, Registry
Description: Percentage of patients 18-75 years of age with diabetes who had a glycemic status assessment (hemoglobin A1c [HbA1c] or glucose management indicator [GMI]) > 9.0% during the measurement period.
Medicare Risk Adjustment (HCC)Billing
E11.3531 maps to a payment category in the CMS-HCC model used to risk-adjust Medicare Advantage payments. Weights are the published community factors for payment year 2027.
Source: CMS Payment Year 2027 risk adjustment mappings and model software. Weights are relative factors, not dollar amounts; a beneficiary's total RAF also includes demographics and interactions. Browse all CMS-HCC categories.
Coding GuidelinesGuidance
The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system. As many codes within a particular category as are necessary to describe all of the complications of the disease may be used. They should be sequenced based on the reason for a particular encounter. Assign as many codes from categories E08 - E13 as needed to identify all of the associated conditions that the patient has.
If the type of diabetes mellitus is not documented in the medical record the default is E11.-, Type 2 diabetes mellitus.
Source: ICD-10-CM Official Guidelines for Coding and Reporting, FY 2027, published by CMS and the National Center for Health Statistics.
Instructional NotesGuidance
Instructions from the official ICD-10-CM Tabular List that apply to E11.3531: its own notes plus those printed at E11.35, E11, and Chapter 4. A note printed at a category, block or chapter applies to every code under it.
Includes
Further defines, or gives examples of, the content of the category.
- diabetes (mellitus) due to insulin secretory defect
- diabetes NOS
- insulin resistant diabetes (mellitus)
Excludes1
Not coded here: the excluded code is never reported together with this one, unless the two conditions are unrelated.
- diabetes mellitus due to underlying condition (E08.-)
- drug or chemical induced diabetes mellitus (E09.-)
- gestational diabetes (O24.4-)
- neonatal diabetes mellitus (P70.2)
- postpancreatectomy diabetes mellitus (E13.-)
- postprocedural diabetes mellitus (E13.-)
- secondary diabetes mellitus NEC (E13.-)
- type 1 diabetes mellitus (E10.-)
Use Additional Code
Add a second code, after this one, to fully describe the condition.
Notes
General instructions on how these codes are used.
- All neoplasms, whether functionally active or not, are classified in Chapter 2. Appropriate codes in this chapter (i.e. E05.8, E07.0, E16-E31, E34.-) may be used as additional codes to indicate either functional activity by neoplasms and ectopic endocrine tissue or hyperfunction and hypofunction of endocrine glands associated with neoplasms and other conditions classified elsewhere.
7th Character
Every code in the category takes a 7th character from the listed values, with the placeholder X filling any empty positions before it.
- One of the following 7th characters is to be assigned to codes in subcategory E11.35 to designate laterality of the disease:
- 1right eye this code
- 2left eye
- 3bilateral
- 9unspecified eye
Source: CMS ICD-10-CM Tabular List. How to read instructional notes.
Referenced in Other NotesGuidance
Instructional notes printed at other codes that name E11.3531, its category, or a range that includes it.
Excludes1 6
These codes carry an Excludes1 note naming E11.3531: they are not reported together with it, unless the two conditions are unrelated.
- E08 Diabetes mellitus due to underlying conditiontype 2 diabetes mellitus (E11.-) names E11.-, which includes this code
- E09 Drug or chemical induced diabetes mellitustype 2 diabetes mellitus (E11.-) names E11.-, which includes this code
- E10 Type 1 diabetes mellitustype 2 diabetes mellitus (E11.-) names E11.-, which includes this code
- E87.2 Acidosisdiabetic acidosis - see categories E08-E10, E11, E13 with ketoacidosis names E11, which includes this code
- H36 Retinal disorders in diseases classified elsewherediabetic retinopathy (E08.3-, E09.3-, E10.3-, E11.3-, E13.3-) names E11.3-, which includes this code
- E11.A Type 2 diabetes mellitus without complications in remission
Excludes2 3
These codes carry an Excludes2 note naming E11.3531: its condition is not part of those codes, and both may be reported when the patient has both.
- E87.0 Hyperosmolality and hypernatremiadiabetes with hyperosmolarity (E08, E09, E11, E13 with final characters .00 or .01) names E11, which includes this code
- Chapter 7 (H00-H59) Diseases of the eye and adnexadiabetes mellitus related eye conditions (E09.3-, E10.3-, E11.3-, E13.3-) names E11.3-, which includes this code
- H35 Other retinal disorders
Use Additional Code 2
These codes say to use an additional code from the note, and E11.3531 is one of the codes named.
- O24.1 Pre-existing type 2 diabetes mellitus, in pregnancy, childbirth and the puerperiumfrom category E11 to further identify any manifestations names E11, which includes this code
- O24.3 Unspecified pre-existing diabetes mellitus in pregnancy, childbirth and the puerperiumfrom category E11 to further identify any manifestation names E11, which includes this code
Clinical ClassificationClinical
AHRQ’s CCSR groups this code into broader clinical categories.
Clinical InformationClinical
Diabetes Mellitus, Type 2
a subclass of diabetes mellitus that is not insulin-responsive or dependent (niddm). it is characterized initially by insulin resistance and hyperinsulinemia; and eventually by glucose intolerance; hyperglycemia; and overt diabetes. type ii diabetes mellitus is no longer considered a disease exclusively found in adults. patients seldom develop ketosis but often exhibit obesity.
Patient EducationClinical
Diabetes Type 2
Type 2 diabetes is a disease in which your blood glucose, or blood sugar, levels are too high. Glucose is your main source of energy. It comes from the foods you eat. A hormone called insulin helps the glucose get into your cells to give them energy. If you have diabetes, your body doesn't make enough insulin or doesn't use insulin well.
The full article covers:
- What is type 2 diabetes?
- What causes type 2 diabetes?
- Who is at risk for type 2 diabetes?
- What are the symptoms of type 2 diabetes?
- How is type 2 diabetes diagnosed?
- What are the treatments for type 2 diabetes?
- Can type 2 diabetes be prevented?
Read the full article at MedlinePlus
Courtesy of MedlinePlus, a service of the U.S. National Library of Medicine.
Convert E11.3531 to ICD-9-CMHistory
The closest ICD-9-CM equivalents under the General Equivalence Mappings.
Code History & ChangesHistory
Replacement E11.3531 replaces the following previously assigned code(s):
- E11.351 - Type 2 diabetes w prolif diabetic rtnop w macular edema
Questions About E11.3531Overview
Is E11.3531 a billable code?
Yes. This is a billable ICD-10-CM code, specific enough to report type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye on HIPAA-covered claims from October 1, 2026 through September 30, 2027.
What does the 7th character 1 in E11.3531 mean?
The final character 1 means right eye, in this case for the type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula. It comes from the 7th character list in the CMS Tabular List for this category.
What MS-DRG does E11.3531 group to?
When type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye is the principal diagnosis on an inpatient stay, it groups to MS-DRG 125, 8, 10, 19, 124, with relative weights from 0.7699 to 7.5461 depending on complications. Higher weights mean higher Medicare reimbursement.
Can E11.3531 be reported with a code from E08?
Not as a rule. The Excludes1 note at E11, which applies to E11.3531, lists "diabetes mellitus due to underlying condition (E08.-)". An Excludes1 note means the excluded code is never reported together with this one; the only exception is when the two conditions are unrelated to each other (Official Guidelines, Section I.A.12.a).
Does E11.3531 need an additional code?
When the condition applies, yes. The Use Additional Code note at E11, which applies to E11.3531, reads: 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). The additional code is reported after E11.3531.
What HCC is E11.3531?
E11.3531 (type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye) maps to CMS-HCC Category 37 (Diabetes with Chronic Complications), commonly written as HCC 37, in the CMS-HCC V28 model used for Medicare Advantage risk adjustment in payment year 2027. It mapped to HCC 18 under the retired V24 model. It also maps in the PACE (CMS-HCC V22), ESRD (V21), and ESRD (V24) models. In the Part D prescription drug model it maps to RxHCC 30.
Does E11.3531 risk-adjust for Medicare Advantage payment?
Yes. When documented and reported on a Medicare Advantage encounter, E11.3531 adds a risk adjustment factor of about 0.166 to the beneficiary's RAF score for a community, non-dual, aged enrollee (published V28 weights range from 0.166 to 0.280 depending on the payment segment). A more severe related category (HCC 35 and HCC 36) supersedes it when both are reported. See the full factor table on the HCC 37 category page.
