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ICD-10 Guide
ICD-10 CodesE10.3413

E10.3413

Billable

Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema (bilateral)

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 E10.3413 is a billable code used to indicate a diagnosis of type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema (bilateral).

Key Diagnostic Point:

E10.3413 refers to a specific condition in which a patient has Type 1 diabetes mellitus accompanied by severe nonproliferative diabetic retinopathy (NPDR) and bilateral macular edema. Type 1 diabetes is characterized by the autoimmune destruction of insulin-producing beta cells in the pancreas, leading to absolute insulin deficiency. Diabetic retinopathy is a common complication of diabetes, resulting from damage to the retinal blood vessels due to chronic hyperglycemia. Severe NPDR indicates significant retinal changes, including extensive retinal hemorrhages and exudates, while macular edema refers to the accumulation of fluid in the macula, the central part of the retina responsible for sharp vision. This condition can lead to vision impairment and requires careful management of blood glucose levels, often necessitating insulin therapy and regular ophthalmologic evaluations. The presence of bilateral macular edema further complicates the clinical picture, as it can significantly affect visual acuity and quality of life.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Multiple conditions coded together (diabetes and retinopathy)
  • Specificity required for the type of retinopathy and edema
  • Need for accurate documentation of severity and laterality
  • Potential for overlapping symptoms with other diabetic complications

Audit Risk Factors

  • Inadequate documentation of retinopathy severity
  • Failure to document bilateral involvement
  • Lack of HbA1c levels in medical records
  • Insufficient detail on insulin management

Specialty Focus

Medical Specialties

Endocrinology

Documentation Requirements

Detailed records of diabetes management, including insulin types, dosages, and HbA1c levels.

Common Clinical Scenarios

Patients presenting with uncontrolled diabetes, requiring insulin adjustments and monitoring for complications.

Billing Considerations

Ensure comprehensive documentation of diabetes management and any referrals to ophthalmology.

Ophthalmology

Documentation Requirements

Thorough retinal examination findings, including descriptions of NPDR and macular edema.

Common Clinical Scenarios

Patients with diabetes presenting for routine eye exams or with vision changes.

Billing Considerations

Document the severity of retinopathy and any treatments provided, such as laser therapy.

Coding Guidelines

Inclusion Criteria

Use E10.3413 When
  • According to ICD
  • 10 coding guidelines, E10
  • 3413 should be used when the patient has Type 1 diabetes with severe NPDR and bilateral macular edema
  • Coders must ensure that documentation supports the diagnosis and that all components of the code are met, including the severity of retinopathy and the presence of edema

Exclusion Criteria

Do NOT use E10.3413 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

92014CPT Code

Ophthalmological examination, comprehensive, established patient

Clinical Scenario

Used for routine eye exams in patients with diabetes.

Documentation Requirements

Document the findings of the eye exam, including retinopathy severity.

Specialty Considerations

Ophthalmologists should ensure detailed notes on retinal findings.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of diabetes-related complications, improving the accuracy of patient records and facilitating better management of chronic conditions.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of diabetes-related complications, improving the accuracy of patient records and facilitating better management of chronic conditions.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of diabetes-related complications, improving the accuracy of patient records and facilitating better management of chronic conditions.

Resources

Clinical References

  • •
    American Diabetes Association
  • •
    American Academy of Ophthalmology

Coding & Billing References

  • •
    American Diabetes Association
  • •
    American Academy of Ophthalmology

Frequently Asked Questions

What is the significance of coding E10.3413?

Coding E10.3413 accurately reflects the severity of diabetic retinopathy and the presence of macular edema, which are critical for appropriate management and treatment planning.

How often should patients with E10.3413 be monitored?

Patients should be monitored regularly, typically every 6 to 12 months, depending on the severity of their retinopathy and overall diabetes control.