ICD-10 Coding for Retinopathy Eye Examination
For a patient undergoing an eye exam specifically for retinopathy screening or evaluation, the appropriate ICD-10 code depends on the clinical context: use Z13.5 for encounter for screening for eye and ear disorders when performing routine diabetic retinopathy screening, or use the specific retinopathy code (E11.3xx series for type 2 diabetes with retinopathy, E10.3xx series for type 1 diabetes) when the patient has known diabetic retinopathy requiring follow-up examination.
Primary Screening Codes
Z13.5 is the appropriate code for encounter for screening for eye and ear disorders when performing routine diabetic retinopathy screening in asymptomatic patients without known retinopathy 1
For patients with diabetes but no documented retinopathy undergoing their initial or routine screening exam, Z13.5 should be the primary code, with the diabetes code (E11.9 for type 2 or E10.9 for type 1) as a secondary diagnosis 1
Codes for Known Retinopathy
When diabetic retinopathy is already documented and the patient is presenting for follow-up examination, use the specific diabetic retinopathy codes as the primary diagnosis 1:
- E11.31x series for type 2 diabetes with mild nonproliferative diabetic retinopathy
- E11.32x series for type 2 diabetes with moderate nonproliferative diabetic retinopathy
- E11.33x series for type 2 diabetes with severe nonproliferative diabetic retinopathy
- E11.34x series for type 2 diabetes with proliferative diabetic retinopathy
- (Use E10.3xx series for type 1 diabetes with corresponding retinopathy stages)
The sixth character in these codes specifies laterality and presence of macular edema, which must be documented for complete coding 1
Screening Frequency and Documentation
Patients with type 2 diabetes should have initial comprehensive eye examination at diagnosis, while type 1 diabetes patients should be screened within 5 years of diagnosis 1
Patients without retinopathy should be screened every 1-2 years, while those with documented retinopathy require more frequent examinations: mild retinopathy annually, moderate retinopathy every 3-6 months, and severe retinopathy every 3 months 1
Documentation must include visual acuity and comprehensive retinal examination findings to support the appropriate code selection 1
Common Coding Pitfalls
Avoid using symptom codes (such as visual disturbance codes) as the primary diagnosis when the specific purpose is diabetic retinopathy screening or follow-up 2
Do not code for "toxic maculopathy" (H35.38) unless specifically dealing with drug-induced retinopathy, as this code has been misused in clinical practice for various retinopathies 3
The ICD-10-CM system requires much greater specificity than ICD-9, with laterality (right eye, left eye, bilateral, unspecified) being mandatory for most eye codes 4, 5
When abnormal findings are detected during screening, the specific retinopathy code should replace the screening code as the primary diagnosis, with the screening code potentially used as a secondary code to indicate the encounter type 1
Additional Considerations for Macular Edema
If diabetic macular edema is present, this must be specified in the sixth character of the diabetic retinopathy code 1
Center-involving diabetic macular edema requires immediate referral to ophthalmology and should be coded with the appropriate sixth character indicating macular edema with involvement of the center of the macula 1