ICD-10 Coding for Retinopathy(E10.311, E11.359)
Complete ICD-10-CM coding and documentation guide for Retinopathy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Retinopathy
E08-E13Primary Range
Diabetes mellitus codes with complications
Primary range for diabetic retinopathy, detailing specific complications like retinopathy and macular edema.
Retinal disorders
Includes specific retinal conditions such as hypertensive retinopathy and retinal edema.
Hypertensive diseases
Used in conjunction with retinopathy codes to indicate hypertensive retinopathy.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| E10.311 | Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema | Use when documenting type 1 diabetes with retinopathy and macular edema. |
|
| E11.359 | Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema | Use when documenting type 2 diabetes with proliferative retinopathy without macular edema. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for diabetic retinopathy
Essential facts and insights about Retinopathy
Primary ICD-10-CM Codes for retinopathy
Decision Criteria
clinical Criteria
- Presence of macular edema confirmed by OCT.
documentation Criteria
- Type 1 diabetes and retinopathy stage must be specified.
Applicable To
- Type 1 diabetes with retinopathy and macular edema
Excludes
- Type 2 diabetes with retinopathy
Clinical Validation Requirements
- OCT showing macular edema
- HbA1c >7% within 90 days
Code-Specific Risks
- Ensure macular edema is documented; otherwise, use E10.319.
Coding Notes
- Ensure diabetes type and presence of macular edema are clearly documented.
E11.359 - Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema
Use when documenting type 2 diabetes with proliferative retinopathy without macular edema.
Applicable To
- Type 2 diabetes with proliferative retinopathy
Excludes
- Proliferative retinopathy with macular edema
Clinical Validation Requirements
- FFA showing neovascularization
- Absence of macular edema on OCT
Coding Notes
Ensure documentation specifies absence of macular edema.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Retinopathy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code E10.311.
Impact
Clinical: Leads to inappropriate treatment plans., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims and audits.
Mitigation Strategy
Use specific terminology for retinopathy stages., Include imaging results in documentation.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Always document laterality and presence/absence of macular edema.
Impact
Using unspecified codes when specific codes are available.
Mitigation Strategy
Always document specific findings and stages of retinopathy.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Retinopathy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Retinopathy
Use these documentation templates to ensure complete and accurate documentation for Retinopathy. These templates include all required elements for proper coding and billing.
Diabetic Eye Exam
Specialty: OphthalmologyRequired Elements
- Visual Acuity
- Dilated Exam Findings
- Imaging Results
- Assessment with Specific Terminology
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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