2027 ICD-10-CM Diagnosis Code E13.3551Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye
ICD-10-CM Codes›E00–E89›E08-E13›E13
- Billable — Valid for Submission
- Risk Adjusts — HCC 37
- 7th Character 1 — Right Eye
- Chronic Condition
E13.3551 is a billable ICD-10-CM diagnosis code for other specified diabetes mellitus with stable proliferative diabetic retinopathy, 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, due to underlying condition, drug or chemical induced, or other specified type; and Retinal and vitreous conditions.
For Medicare Advantage risk adjustment, E13.3551 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.
Code Identity
Code Classification
Quality Payment Program MeasuresBilling
Medicare quality measures that can apply when E13.3551 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
E13.3551 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.
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 E13.3551: its own notes plus those printed at E13.35, E13, 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 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: the excluded code is never reported together with this one, unless the two conditions are unrelated.
- diabetes (mellitus) due to autoimmune process (E10.-)
- diabetes (mellitus) due to immune mediated pancreatic islet beta-cell destruction (E10.-)
- diabetes mellitus due to underlying condition (E08.-)
- drug or chemical induced diabetes mellitus (E09.-)
- gestational diabetes (O24.4-)
- neonatal diabetes mellitus (P70.2)
- 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 E13.35 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 E13.3551, its category, or a range that includes it.
Excludes1 14
These codes carry an Excludes1 note naming E13.3551: they are not reported together with it, unless the two conditions are unrelated.
- E08 Diabetes mellitus due to underlying conditionpostpancreatectomy diabetes mellitus (E13.-) names E13.-, which includes this code
- E08 Diabetes mellitus due to underlying conditionpostprocedural diabetes mellitus (E13.-) names E13.-, which includes this code
- E08 Diabetes mellitus due to underlying conditionsecondary diabetes mellitus NEC (E13.-) names E13.-, which includes this code
- E09 Drug or chemical induced diabetes mellituspostpancreatectomy diabetes mellitus (E13.-) names E13.-, which includes this code
- E09 Drug or chemical induced diabetes mellituspostprocedural diabetes mellitus (E13.-) names E13.-, which includes this code
- E09 Drug or chemical induced diabetes mellitussecondary diabetes mellitus NEC (E13.-) names E13.-, which includes this code
- E10 Type 1 diabetes mellituspostpancreatectomy diabetes mellitus (E13.-) names E13.-, which includes this code
- E10 Type 1 diabetes mellituspostprocedural diabetes mellitus (E13.-) names E13.-, which includes this code
- E10 Type 1 diabetes mellitussecondary diabetes mellitus NEC (E13.-) names E13.-, which includes this code
- E11 Type 2 diabetes mellituspostpancreatectomy diabetes mellitus (E13.-) names E13.-, which includes this code
- E11 Type 2 diabetes mellituspostprocedural diabetes mellitus (E13.-) names E13.-, which includes this code
- E11 Type 2 diabetes mellitussecondary diabetes mellitus NEC (E13.-) names E13.-, which includes this code
- E87.2 Acidosisdiabetic acidosis - see categories E08-E10, E11, E13 with ketoacidosis names E13, which includes this code
- H36 Retinal disorders in diseases classified elsewherediabetic retinopathy (E08.3-, E09.3-, E10.3-, E11.3-, E13.3-) names E13.3-, which includes this code
Excludes2 3
These codes carry an Excludes2 note naming E13.3551: 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 E13, 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 E13.3-, which includes this code
- H35 Other retinal disorders
Code First 1
These codes say to code first a condition named in the note, and E13.3551 is one of the conditions named.
Use Additional Code 3
These codes say to use an additional code from the note, and E13.3551 is one of the codes named.
- O24.8 Other pre-existing diabetes mellitus in pregnancy, childbirth, and the puerperiumfrom categories E08, E09 and E13 to further identify any manifestation names E13, which includes this code
- O24.9 Unspecified diabetes mellitus in pregnancy, childbirth and the puerperiumfrom categories E08, E09 and E13 to further identify any manifestation names E13, which includes this code
- Z90.41 Acquired absence of pancreasdiabetes mellitus, postpancreatectomy (E13.-) names E13.-, which includes this code
Clinical ClassificationClinical
AHRQ’s CCSR groups this code into broader clinical categories.
Patient EducationClinical
Diabetes
Diabetes, also known as diabetes mellitus, is a disease in which your blood glucose, or blood sugar, levels are too high. Glucose is your body's main source of energy. Your body can make glucose, but it also comes from the food you eat. Insulin is a hormone made by your pancreas.
The full article covers:
- What is diabetes?
- What are the types of diabetes?
- What causes diabetes?
- Who is more likely to develop diabetes?
- What are the symptoms of diabetes?
- How is diabetes diagnosed?
- What are the treatments for diabetes?
- Can diabetes be prevented?
Read the full article at MedlinePlus
Courtesy of MedlinePlus, a service of the U.S. National Library of Medicine.
Convert E13.3551 to ICD-9-CMHistory
The closest ICD-9-CM equivalents under the General Equivalence Mappings.
Code History & ChangesHistory
Replacement E13.3551 replaces the following previously assigned code(s):
- E13.351 - Oth diabetes w prolif diabetic retinopathy w macular edema
Questions About E13.3551Overview
Is E13.3551 a billable code?
Yes. This is a billable ICD-10-CM code, specific enough to report other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye on HIPAA-covered claims from October 1, 2026 through September 30, 2027.
What does the 7th character 1 in E13.3551 mean?
The final character 1 means right eye, in this case for the other specified diabetes mellitus with stable proliferative diabetic retinopathy. It comes from the 7th character list in the CMS Tabular List for this category.
What MS-DRG does E13.3551 group to?
When other specified diabetes mellitus with stable proliferative diabetic retinopathy, 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 E13.3551 be reported with a code from E10?
Not as a rule. The Excludes1 note at E13, which applies to E13.3551, lists "diabetes (mellitus) due to autoimmune process (E10.-)". 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 E13.3551 need an additional code?
When the condition applies, yes. The Use Additional Code note at E13, which applies to E13.3551, 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 E13.3551.
What HCC is E13.3551?
E13.3551 (other specified diabetes mellitus with stable proliferative diabetic retinopathy, 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 E13.3551 risk-adjust for Medicare Advantage payment?
Yes. When documented and reported on a Medicare Advantage encounter, E13.3551 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.
