Medical Codes for Reporting Diabetic Retinopathy– A Common Eye Condition

Read about diabetic retinopathy –an eye condition that occurs due to the complication of diabetes – including its ICD-10 codes and CPT codes. 

Regarded as the leading cause of preventable blindness, diabetic retinopathy – as the name suggests – is an eye condition that occurs due to the complications of diabetes. The condition causes progressive damage to the retina - the light-sensitive lining at the back of the eye. It occurs when tiny blood vessels leak blood and other fluids causing the retinal tissue to swell, resulting in cloudy or blurred vision. Usually, the condition affects both the eyes. The longer the person has diabetes, the more likely they will develop diabetic retinopathy. If left untreated, diabetic retinopathy can cause blindness. For ophthalmologists diagnosing and treating diabetic retinopathy, a physician billing service could provide significant support as regards medical coding and documentation.

Anyone who has had diabetes for a long period of time and poor control of their blood sugar level has the risk of developing diabetic retinopathy. In fact, it can develop in anyone who has type 1 or type 2 diabetes. There are two different types of diabetic retinopathy namely - early diabetic retinopathy and advanced diabetic retinopathy. According to a 2018 American Eye-Q ® survey conducted by the American Optometric Association (AOA), nearly half of Americans didn't know whether diabetic eye diseases have visible symptoms (often which the early stages of diabetic retinopathy does not). In the early stages of this condition, people may not experience any specific symptoms. However, as the condition progresses, one may experience certain symptoms like – blurred/ fluctuating vision, vision loss, spots or dark strings floating in your vision (floaters) and dark or empty areas in the vision.

Coding for Diabetic Retinopathy – ICD-10 and CPT codes

Diagnosis of diabetic retinopathy involves a comprehensive dilated eye exam wherein eye drops are placed in the eyes to dilate the pupils and allow ophthalmologists to gain a better view inside the eyes. In addition, fluoresce in angiography and optical coherence tomography (OCT) will also be performed to check for abnormalities in the inside and outside parts of the eyes.

While documenting this eye condition, the documentation should clearly show if the diabetic retinopathy is proliferative or non-proliferative. If non-proliferative – whether it is mild, moderate, or severe, and whether there is macular edema. For appropriate reimbursement, healthcare providers should ensure that the diagnostic, procedure, and therapeutic codes on insurance billing claims for diabetic retinopathy accurately reflect services provided. The ICD-10 codes for diabetic retinopathy are listed in the diabetes section (E08-E13) of Chapter 4, Endocrine, Nutritional and Metabolic Diseases, while the most common retinal complications are in Chapter 7. There are ICD-10 codes for non-proliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR), wet age-related macular degeneration (AMD), and dry age-related macular degeneration (AMD). There are many codes under the following code sets for diabetic retinopathy –

Type 1 Diabetes, Non-proliferative Retinopathy

E10.31 – Type 1 diabetes mellitus with unspecified diabetic retinopathy

E10.32 – Type 1 diabetes mellitus with mild non-proliferative diabetic retinopathy

• E10.329 – Type 1 diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema

E10.33 – Type 1 diabetes mellitus with moderate non-proliferative diabetic retinopathy

• E10.339 – Type 1 diabetes mellitus with moderate non-proliferative diabetic retinopathy without macular edema

E10.34 – Type 1 diabetes mellitus with severe non-proliferative diabetic retinopathy

• E10.341 – Type 1 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema
• E10.349 – Type 1 diabetes mellitus with severe non-proliferative diabetic retinopathy without macular edema

Type 1 Diabetes, Proliferative Retinopathy

• E10.35 – Type 1 diabetes mellitus with proliferative diabetic retinopathy
• E10.351 – Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema
• E10.352 – Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula
• E10.353 – Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula
• E10.354 – Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment
• E10.355 – Type 1 diabetes mellitus with stable proliferative diabetic retinopathy
• E10.359 – Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema

Type 2 Diabetes, Non-proliferative Retinopathy

E11.31 – Type 2 diabetes mellitus with unspecified diabetic retinopathy

E11.32 – Type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy

• E11.321 – Type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema
• E11.329 – Type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema

E11.33 – Type 2 diabetes mellitus with moderate non-proliferative diabetic retinopathy

• E11.331 – Type 2 diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema
• E11.339 – Type 2 diabetes mellitus with moderate non-proliferative diabetic retinopathy without macular edema

Type 2 Diabetes, Proliferative Retinopathy

E11.34 – Type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy

• E11.341 – Type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema
• E11.349 – Type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy without macular edema

E11.35 – Type 2 diabetes mellitus with proliferative diabetic retinopathy

• E11.351 – Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema
• E11.352 – Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula
• E11.353 – Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula
• E11.354 – Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment
• E11.355 – Type 2 diabetes mellitus with stable proliferative diabetic retinopathy
• E11.359 – Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema

Treatment for this condition depends largely on the type of diabetic retinopathy a person has and its severity. Depending on the specific problems with the retina, treatment options include – injecting medications in to the eyes, Photocoagulation, Pan-retinal photocoagulation and vitrectomy. Treatment modalities can slow or stop the progression of diabetic retinopathy.CPT codes diabetic retinopathy include – 

• 67105 Repair of retinal detachment, including drainage of subretinal fluid when performed; photocoagulation
• 67145 Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) w/o drainage, 1 or more sessions; photocoagulation
• 67210 Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; photocoagulation
• 67220 Destruction of localized lesion of choroid (eg, choroidal neovascularization); photocoagulation 1 or more sessions
• 67228 Treatment of extensive or progressive retinopathy; (eg diabetic retinopathy), photocoagulation
• 67229 Treatment of extensive or progressive retinopathy, 1 or more sessions, preterm infant; (less than 37 weeks gestation at birth), performed from birth up to 1 year of age (e.g., retinopathy of prematurity), photocoagulation or cryotherapy
• 66821 YAG capsulotomy surgery
• 65855 Selective laser trabeculoplasty
• 66761 Laser peripheral iridotomy
• 67210 Focal photocoagulation
• 66852 Removal of lens material; pars plana approach, with or without vitrectomy
• 67036 Vitrectomy, mechanical, pars plana approach
• 67039 Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation
• 67040 Vitrectomy, mechanical, pars plana approach; with endolaserpanretinal photocoagulation
• 67041 Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular

It is not always possible to prevent diabetic retinopathy. However, conducting regular eye exams, regular control of blood sugar and blood pressure, and early intervention for vision problems can help prevent severe vision loss in the long run. 

Clear documentation is important for accurate medical billing. To submit error-free medical claims using the correct medical codes, healthcare practices can rely on the services of an experienced medical billing company.

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