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BETA v.3.0

2025 ICD-10-CM code E11.31

Type 2 diabetes mellitus with unspecified diabetic retinopathy.

Use additional codes to specify any associated conditions, such as macular edema or proliferative diabetic retinopathy, if documented. If the type of retinopathy is not specified, use E11.31.

The medical necessity for the diagnosis and treatment of diabetic retinopathy stems from its potential to cause vision impairment or blindness. Early detection and appropriate intervention are crucial for preserving vision.

Diabetic retinopathy is diagnosed and managed by ophthalmologists or optometrists. The overall management of diabetes, including controlling blood sugar levels, blood pressure, and cholesterol, often involves primary care physicians, endocrinologists, and other healthcare professionals.

In simple words: This code signifies type 2 diabetes, a condition where the body doesn't use sugar properly, along with an eye problem called diabetic retinopathy, where the blood vessels in the back of the eye are damaged. The specific type of retinopathy isn't identified.

Type 2 diabetes mellitus with unspecified diabetic retinopathy refers to a complication of type 2 diabetes, a chronic metabolic disorder characterized by elevated blood glucose levels due to the body's ineffective use of insulin. This specific code indicates the presence of diabetic retinopathy, a microvascular complication affecting the blood vessels in the retina, without specifying the stage or type of retinopathy.

Example 1: A 55-year-old patient with a history of type 2 diabetes presents with blurred vision. Upon examination, the ophthalmologist diagnoses unspecified diabetic retinopathy., A pregnant woman with gestational diabetes undergoes an eye examination, revealing the presence of diabetic retinopathy, but the type is not specified., A patient with long-standing type 2 diabetes and poorly controlled blood sugar levels develops vision changes. The ophthalmologist diagnoses unspecified diabetic retinopathy.

Documentation should include the type of diabetes (type 2), the presence of retinopathy, and any associated symptoms or clinical findings related to the retinopathy. If any specific type of retinopathy (e.g., non-proliferative, proliferative, maculopathy) is identified, it should be documented and coded accordingly.

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