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ICD-10 Guide
ICD-10 CodesE10.359

E10.359

Billable

Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema

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

Code Description

ICD-10 E10.359 is a billable code used to indicate a diagnosis of type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema.

Key Diagnostic Point:

E10.359 refers to Type 1 diabetes mellitus characterized by the presence of proliferative diabetic retinopathy (PDR) without associated macular edema. PDR is a severe form of diabetic retinopathy where new blood vessels grow in the retina, which can lead to vision loss. In Type 1 diabetes, the body does not produce insulin, leading to elevated blood glucose levels that can damage blood vessels over time. The absence of macular edema indicates that while there is significant retinal damage, the central part of the retina (the macula) is not swollen, which is a critical distinction as macular edema often leads to more severe visual impairment. Management of this condition typically involves strict glycemic control, regular ophthalmologic evaluations, and may include laser therapy to prevent further retinal damage. Monitoring HbA1c levels is crucial, as maintaining them below 7% can help reduce the risk of complications such as PDR.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiation between types of diabetic retinopathy
  • Need for precise documentation of retinopathy severity
  • Understanding of diabetes management and insulin therapy
  • Knowledge of associated complications and their coding

Audit Risk Factors

  • Inadequate documentation of retinopathy severity
  • Failure to specify absence of macular edema
  • Incorrect coding of diabetes type
  • Lack of supporting clinical evidence for the diagnosis

Specialty Focus

Medical Specialties

Endocrinology

Documentation Requirements

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

Common Clinical Scenarios

Patients presenting with uncontrolled blood sugar levels and complications such as retinopathy.

Billing Considerations

Ensure that all diabetes-related complications are documented and linked to the primary diagnosis.

Ophthalmology

Documentation Requirements

Comprehensive eye exam reports detailing the presence and severity of diabetic retinopathy.

Common Clinical Scenarios

Patients undergoing routine eye exams who are diagnosed with proliferative diabetic retinopathy.

Billing Considerations

Clear documentation of the absence of macular edema is crucial for accurate coding.

Coding Guidelines

Inclusion Criteria

Use E10.359 When
  • According to ICD
  • 10 guidelines, E10
  • 359 should be used when there is clear documentation of Type 1 diabetes with proliferative diabetic retinopathy without macular edema
  • It is essential to ensure that the documentation supports the diagnosis and that the absence of macular edema is explicitly stated

Exclusion Criteria

Do NOT use E10.359 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

92014CPT Code

Ophthalmological examination, comprehensive, established patient

Clinical Scenario

Used during routine eye exams for patients with diabetes.

Documentation Requirements

Complete eye exam report detailing findings.

Specialty Considerations

Ophthalmologists should ensure that all findings are documented to support coding.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of diabetic complications, improving the accuracy of diagnoses and treatment plans. E10.359 provides a clear distinction between types of diabetic retinopathy, which aids in better patient management and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of diabetic complications, improving the accuracy of diagnoses and treatment plans. E10.359 provides a clear distinction between types of diabetic retinopathy, which aids in better patient management and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of diabetic complications, improving the accuracy of diagnoses and treatment plans. E10.359 provides a clear distinction between types of diabetic retinopathy, which aids in better patient management and resource allocation.

Resources

Clinical References

  • •
    American Diabetes Association

Coding & Billing References

  • •
    American Diabetes Association

Frequently Asked Questions

What is the significance of specifying 'without macular edema'?

Specifying 'without macular edema' is crucial as it indicates a different level of severity and management for diabetic retinopathy, impacting treatment decisions and coding accuracy.