What Does ICD-10 Code E11.3313 Mean?
ICD-10-CM code E11.3313 describes Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral — meaning the patient has confirmed Type 2 diabetes that has caused moderate-stage retinal damage accompanied by macular swelling in both eyes. This is a billable, specific diagnosis code valid for HIPAA-covered transactions from October 1, 2025 through September 30, 2026 under the 2026 ICD-10-CM edition.
Key attributes at a glance:
- Valid and billable for FY2026 (effective October 1, 2025)
- Laterality: Bilateral — both right and left eyes are affected
- Retinopathy severity: Moderate nonproliferative (NPDR) stage
- Complicating feature: Diabetic macular edema (DME) confirmed
- Applicable setting: Outpatient and inpatient encounters
- Linked to Medicare Quality Payment Program (QPP) measure: Diabetes: HbA1c Poor Control (>9%)
What Conditions and Diagnoses Does E11.3313 Cover?
E11.3313 applies when a Type 2 diabetic patient presents with both moderate-stage nonproliferative retinopathy and clinically significant macular edema confirmed in both eyes. The retinal changes captured here are distinct from mild or severe NPDR and from the neovascularization that defines proliferative disease.
Clinical presentations appropriately captured by this code include:
- Dot and blot hemorrhages with hard exudates on fundus exam, bilateral
- Intraretinal microvascular abnormalities (IRMA) at the moderate threshold, both eyes
- Macular thickening on optical coherence tomography (OCT) confirming diabetic macular edema bilaterally
- Reduced visual acuity attributable to central macular involvement in both eyes
- Incidental bilateral finding during routine diabetic eye exam in a known T2DM patient
What Does E11.3313 Specifically Exclude?
The following conditions have dedicated codes and must not be reported as E11.3313:
- Type 1 diabetes mellitus — use E10.33×3 series instead (E10.-)
- Drug- or chemical-induced diabetes mellitus — use E09.- category
- Gestational diabetes — use O24.4- series
- Secondary diabetes mellitus NEC — use E13.- category
- Postpancreatectomy diabetes — use E13.- category
- Severe NPDR with macular edema, bilateral — use E11.3413
- Proliferative diabetic retinopathy with macular edema, bilateral — use E11.3513
When Is E11.3313 the Right Code to Use?
Selecting E11.3313 requires matching three simultaneous clinical criteria — diabetes type, retinopathy severity, and laterality. Follow this decision sequence before assigning the code:
- Confirm the diabetes type is Type 2. If the record indicates Type 1, autoimmune origin, or neonatal diabetes, route to the appropriate E10.- or other category.
- Verify the retinopathy stage is moderate NPDR. The ophthalmology note or retinal imaging must specifically document moderate (not mild, not severe, not proliferative) nonproliferative changes.
- Confirm macular edema is present. A diagnosis of NPDR without documented DME maps to E11.3319 (moderate NPDR without macular edema, bilateral) — these are not interchangeable.
- Confirm bilateral involvement. If only one eye is affected, use E11.3311 (right eye) or E11.3312 (left eye). Bilateral requires documentation confirming both eyes show moderate NPDR with DME — do not assume bilateral based on a single-eye exam note.
- Check the treatment context. If the patient is receiving insulin, assign Z79.4 as an additional code. Oral antidiabetic agents require Z79.84; injectable non-insulin drugs require Z79.85.
How Does E11.3313 Differ From E11.3319 and E11.3413?
These three codes are the most frequently confused in this subcategory. Coders must distinguish them by two variables: macular edema presence and retinopathy severity.
| Code | Retinopathy Severity | Macular Edema | Laterality |
|---|---|---|---|
| E11.3313 | Moderate NPDR | Present | Bilateral |
| E11.3319 | Moderate NPDR | Absent | Bilateral |
| E11.3413 | Severe NPDR | Present | Bilateral |
| E11.3513 | Proliferative DR | Present | Bilateral |
| E11.3311 | Moderate NPDR | Present | Right eye only |
| E11.3312 | Moderate NPDR | Present | Left eye only |
In practice, coders frequently encounter situations where the provider documents “moderate diabetic retinopathy” without explicitly stating whether macular edema is present or absent. In these cases, the coder must query the provider before assigning a code — never default to the “without macular edema” version simply because DME is not mentioned.
What Documentation Is Required to Support E11.3313?
What Must the Provider Document in the Clinical Notes?
The ophthalmologist or treating provider’s note must include all of the following to support E11.3313 without audit risk:
- Explicit diabetes type — “Type 2 diabetes mellitus” (not simply “diabetes” or “DM”)
- Retinopathy stage — “Moderate nonproliferative diabetic retinopathy” in both eyes; the word “moderate” must appear, not just “NPDR”
- Macular edema confirmation — “Diabetic macular edema” or “clinically significant macular edema (CSME)” documented as a current finding
- Bilateral specification — documentation that both eyes are affected; laterality must be explicit, not implied
- Causal relationship — linkage between the diabetes and the retinal findings (ICD-10-CM guidelines assume an assumed relationship between diabetes and eye conditions in diabetic patients, but documentation should still reflect this clinically)
- Diabetes management status — current treatment modality (insulin, oral agents, or non-insulin injectables) to support required additional codes
Which Diagnostic or Lab Results Support This Code?
Objective diagnostic findings that substantiate the clinical record include:
- Optical coherence tomography (OCT) report confirming retinal thickening in the macular zone, bilaterally
- Fundus photography with interpretation showing microaneurysms, hemorrhages, and hard exudates consistent with moderate NPDR
- Fluorescein angiography (FA) identifying areas of leakage or non-perfusion appropriate for moderate-stage disease
- Dilated fundus exam findings documented in structured retinal exam format (e.g., ETDRS grading or equivalent)
- HbA1c results — while not required to assign the code, HbA1c supports medical necessity for diabetic eye care services
What Is the Documentation Standard for Inpatient vs. Outpatient Settings?
| Setting | Key Standard |
|---|---|
| Outpatient | Code the confirmed diagnosis as documented by the treating provider; do not code “possible” or “probable” DME |
| Inpatient | Coders may code conditions documented as “probable” or “likely” at the time of discharge per ICD-10-CM Official Coding Guidelines Section II |
| Telehealth eye exam | Same documentation standards apply; OCT results transmitted remotely are acceptable if interpreted by a qualified provider |
How Does E11.3313 Affect Medical Billing and Claims?
E11.3313 is a high-specificity code that directly influences reimbursement pathways, quality metrics, and medical necessity determinations. Key billing considerations include:
- Medicare Quality Payment Program (QPP): This code triggers the Diabetes: HbA1c Poor Control measure — practices should ensure monitoring is documented to avoid negative performance impact
- Medical necessity for anti-VEGF injections: E11.3313 is a supported diagnosis for intravitreal anti-VEGF therapy (e.g., bevacizumab, ranibizumab, aflibercept); payers typically require OCT documentation at each injection encounter
- DRG assignment (inpatient): E11.3313 falls within MS-DRG V43.0 groupings related to diabetes with complications — accurate coding supports appropriate DRG weight
- Electronic submission: Do NOT include the decimal point (submit as E113313) to avoid claim rejection at clearinghouses that do not auto-strip decimals
What CPT or Procedure Codes Are Commonly Billed With E11.3313?
| CPT Code | Description | Typical Pairing Context |
|---|---|---|
| 67028 | Intravitreal injection of pharmacologic agent | Anti-VEGF therapy for DME |
| 67210 | Photocoagulation, macular (focal/grid laser) | Laser treatment for DME |
| 92134 | OCT posterior segment with interpretation, bilateral | Diagnostic imaging at each DME visit |
| 92250 | Fundus photography with interpretation | Retinal documentation, annual diabetic eye exam |
| 92228 | Remote imaging for retinal disease detection | Telehealth-based diabetic retinopathy screening |
| 99213–99215 | Office/outpatient E&M | Diabetic ophthalmology follow-up encounters |
Are There Any Prior Authorization or Coverage Restrictions?
- Most commercial payers require prior authorization for intravitreal anti-VEGF injections when billed with E11.3313; step therapy policies may require laser treatment first
- Medicare Part B covers anti-VEGF drugs for DME under the drug benefit with E11.3313 as a supporting diagnosis; LCD L33786 (or successor) governs coverage criteria in many jurisdictions — verify the applicable LCD for the MAC in your region via CMS.gov
- Some payers apply a bilateral modifier (-50 or RT/LT) requirement even when E11.3313 inherently captures bilateral disease — confirm payer-specific billing rules before submission
What Coding Errors Should You Avoid With E11.3313?
Auditors and RAC reviewers consistently flag the following mistakes in E11.3313 claims:
- Assigning E11.3313 when only one eye is affected. If the exam documents findings in one eye only, use E11.3311 (right) or E11.3312 (left). Bilateral requires bilateral documentation — period.
- Using E11.3313 without documenting macular edema. If the note says “moderate NPDR” with no mention of DME, the correct code is E11.3319. Macular edema must be explicit.
- Failing to add required additional codes. Omitting Z79.4 (insulin use) when the patient is on insulin is a compliance gap flagged in nearly every ophthalmic coding audit.
- Upcoding retinopathy severity. “Moderate” and “severe” NPDR are not interchangeable. Assign E11.3313 only when the provider specifically documents “moderate.”
- Assuming causation without documentation. ICD-10-CM guidelines do allow assumed relationship between diabetes and retinopathy; however, the provider must still document both conditions in the same encounter note.
- Submitting with a decimal point electronically. Claims submitted as E11.3313 (with decimal) may be rejected — submit as E113313 in the electronic transaction.
What Do Auditors Look for When Reviewing Claims With E11.3313?
- OCT report present and dated within 30–90 days of the billed service (varies by payer)
- Provider specialty matches the service (ophthalmology, optometry with appropriate credentialing)
- Medical necessity documentation for anti-VEGF injections — prior imaging and visual acuity findings in the record
- Consistency between the diagnosis code severity and the procedure performed (e.g., anti-VEGF appropriate for DME, not just NPDR without edema)
- HbA1c result in the record supporting active diabetes management
How Does E11.3313 Relate to Other ICD-10 Codes?
Understanding E11.3313’s position in the code hierarchy prevents both undercoding and overcoding in complex diabetic patients.
| Related Code | Relationship Type | Key Distinction |
|---|---|---|
| E11.331 | Parent code | Nonbillable; subcategory header only |
| E11.3311 | Sibling code | Right eye only — use when DME + moderate NPDR is unilateral right |
| E11.3312 | Sibling code | Left eye only — use when DME + moderate NPDR is unilateral left |
| E11.3319 | Sibling code | Moderate NPDR bilateral — without macular edema |
| E11.3413 | Adjacent code | Severe NPDR with DME, bilateral — higher severity stage |
| E11.3513 | Adjacent code | Proliferative DR with DME, bilateral — most advanced stage |
| Z79.4 | Use additional | Insulin use — required when patient is on insulin |
| Z79.84 | Use additional | Oral antidiabetic drugs — required when applicable |
| Z79.85 | Use additional | Injectable non-insulin antidiabetic drugs — required when applicable |
| E10.3313 | Cross-category | Type 1 DM equivalent of E11.3313 — never mix Type 1 and Type 2 codes |
What Is the Correct Code Sequencing When E11.3313 Appears With Other Diagnoses?
Per the ICD-10-CM Official Coding Guidelines (Section I.C.4), diabetes codes follow etiology/manifestation convention:
- Sequence the diabetes code (E11.3313) as the principal or first-listed diagnosis when the encounter is for diabetic retinopathy or its treatment.
- Add Z79.4, Z79.84, or Z79.85 immediately after E11.3313 to identify the treatment modality — this is a mandatory “use additional code” instruction.
- Add any associated condition codes (e.g., hypertension I10, CKD N18.x) as secondary diagnoses per their clinical relevance to the encounter.
- Do not separately code the retinopathy or macular edema with a standalone retinal code — E11.3313 is a combination code that captures both the diabetic origin and the ocular manifestation.
Real-World Coding Scenario — How E11.3313 Is Applied in Practice
A 61-year-old female with a 14-year history of Type 2 diabetes mellitus, managed on insulin glargine and metformin, presents to her retina specialist for a follow-up visit. The provider performs a dilated fundus exam and reviews OCT results. Documentation states: “Bilateral moderate nonproliferative diabetic retinopathy with clinically significant macular edema confirmed on OCT in both eyes. Patient will receive intravitreal bevacizumab injection today bilaterally.”
Correct Code Application
- E11.3313 — Type 2 DM with moderate NPDR with macular edema, bilateral (primary diagnosis — combination code captures DM + retinopathy + DME)
- Z79.4 — Insulin use (required additional code — patient is on insulin glargine)
- Z79.84 — Oral antidiabetic drug use (required — patient also on metformin)
- CPT 67028 × 2 — Intravitreal injection, reported per eye with appropriate modifier (or billed bilaterally per payer instructions)
- CPT 92134 — OCT posterior segment with interpretation
Common Mistake in This Scenario
- Assigning E11.3319 (moderate NPDR without macular edema) because the coder focused on “moderate NPDR” and missed the macular edema documentation
- Omitting Z79.4 because insulin is a chronic medication not listed in the chief complaint
- Reporting CPT 92134 without a linked diagnosis pointing to active retinal monitoring — E11.3313 directly supports medical necessity for this imaging service
Frequently Asked Questions About ICD-10 Code E11.3313
Is ICD-10 Code E11.3313 Valid for Use in 2026?
ICD-10-CM code E11.3313 is valid and billable for fiscal year 2026, effective October 1, 2025 through September 30, 2026, with no changes to its code description or validity status. Coders should verify annually against the official ICD-10-CM release published by CMS to confirm no updates, as diabetic eye condition codes have seen laterality expansions in recent years.
What Is the Difference Between E11.3313 and E11.3319?
E11.3313 is assigned when the patient has moderate nonproliferative diabetic retinopathy with macular edema bilaterally, while E11.3319 applies when bilateral moderate NPDR is present without macular edema. These codes are mutually exclusive — the presence or absence of macular edema must be explicitly documented before selecting between them.
Does E11.3313 Require Additional Codes?
Yes. The ICD-10-CM Official Coding Guidelines include a mandatory “use additional code” instruction with all Type 2 diabetes mellitus codes. When the patient uses insulin, add Z79.4; for oral antidiabetic agents, add Z79.84; for injectable non-insulin drugs such as GLP-1 agonists, add Z79.85. Omitting these codes is a compliance error flagged frequently in coding audits.
Can E11.3313 Be Used for a Patient Who Also Has Type 1 Features?
No. E11.3313 is exclusive to Type 2 diabetes mellitus. If the provider documents Type 1 diabetes, mixed features, or latent autoimmune diabetes in adults (LADA), the appropriate code is drawn from the E10.- category (e.g., E10.3313 for Type 1 with the same ocular findings). Using E11.3313 for a Type 1 patient constitutes a coding inaccuracy that can trigger a payer audit.
What Is the Bilateral Designation “3” in E11.3313?
The seventh character “3” at the end of E11.3313 indicates bilateral involvement — meaning both eyes are affected. The full E11.331x subcategory uses the following laterality convention: 1 = right eye, 2 = left eye, 3 = bilateral. If a patient’s chart only documents findings in one eye at a given encounter, bilateral (3) cannot be used even if the patient has a bilateral diagnosis historically.
Is E11.3313 Covered by Medicare for Anti-VEGF Injections?
Medicare Part B covers intravitreal anti-VEGF drug administration when E11.3313 is among the supporting diagnoses, provided the medical record meets the criteria outlined in the applicable Local Coverage Determination (LCD) for the treating provider’s Medicare Administrative Contractor (MAC). Documentation must include OCT confirmation of macular edema and current visual acuity measurements. Coders should reference CMS.gov to identify the current LCD governing diabetic macular edema treatment in their jurisdiction.
What Happens If the Provider Only Documents Macular Edema Without Specifying Retinopathy Severity?
If the provider documents diabetic macular edema without explicitly staging the retinopathy, the coder must query the provider before assigning E11.3313. Macular edema alone is insufficient — the code requires that the retinopathy be specifically identified as moderate nonproliferative. Assigning E11.3313 without severity documentation creates an unsupported diagnosis that will not withstand audit scrutiny.
Key Takeaways
Every coder working with E11.3313 should internalize these core points:
- E11.3313 is a combination code — it captures Type 2 diabetes, moderate NPDR, macular edema, and bilateral laterality in a single code; do not separately code the retinal manifestations
- Bilateral (digit 3) is not a default — it requires explicit provider documentation that both eyes are affected at moderate NPDR with DME
- Macular edema must be documented — the difference between E11.3313 and E11.3319 hinges entirely on this one clinical finding
- Z79.4, Z79.84, or Z79.85 are mandatory additional codes — never submit E11.3313 alone when the patient’s diabetes treatment is known
- Do not include the decimal point when submitting electronically — use E113313 to prevent claim rejection
- E11.3313 supports medical necessity for OCT imaging, intravitreal injections, and laser photocoagulation — ensure the procedure codes submitted align with the documented condition
- Annual verification against the current ICD-10-CM release from CMS is essential, as diabetic eye codes have been updated in prior years
For additional guidance on medical billing documentation requirements and coding audit preparation related to diabetic retinopathy, refer to the ICD-10-CM Official Coding Guidelines and the AHA Coding Clinic for the most current interpretive guidance.