E10 .

3
RETINOPATHY stage edema laterality

DIABETES 2 mild  1 with 1 right

TYPE 1 3 moderate 9 without 2 left

4 severe 3 bilateral
5 PDR

Retinopathy?

Scribe I  Physician Tip:

E10.9
 I   I   I  Type 1 DM NO YES
without Comp.
No laterality
MILD = microaneurysms only

MODERATE = more than just micro- Proliferative?

aneurysms but less that severe NPDR

SEVERE = Any of the following

(4–2–1 rule) and no signs
of proliferative retinopathy: NO YES 5

• Severe intraretinal hemorrhages

and microaneurysms in each
of four quadrants Macular
Severity?
Edema?
• Definite venous beading
in two or more quadrants

• Moderate IRMA in one 2 3 4

or more quadrants Mild Moderate Severe YES NO

PDR = one or both of the following:

neovascularization or vitreous /
Macular Macular Macular 1 1
pre-retinal hemorrhage Edema? Edema? Edema? E10.351 2 E10.359 2
3 3

Type 1 DM Type 1 DM
with Prolif. with Prolif.
YES NO YES NO YES NO
with ME without ME

1 1 1 1 1 1 chart continues
E10.321 2 E10.329 2 E10.331 2 E10.339 2 E10.341 2 E10.349 2
3 3 3 3 3 3

Type 1 DM Type 1 DM Type 1 DM Type 1 DM Type 1 DM Type 1 DM Sev.

Mild with Mild without Mod. with Mod. without Sev. with without
ME ME ME ME ME ME

©2016 American Academy of Ophthalmology All rights reserved

 E10 . 35
PDR stage laterality
DIABETES
TYPE 1 5 2 TRD invol. macula 1 right
5 3 TRD NOT invol. macula 2 left
5 4 comb. TRD & Rheg RD 3 bilateral
5 5 Stable PDR
Proliferative
Retinopathy

Stable see page 1 for

continued from previous page NO RD? NO
PDR? PDR codes

YES

YES

TRD?

55 1
involving and
E10.355 2
the NO Rhegmatogenus YES
3
Macula? RD?

Type 1 DM
w/stable PDR
YES NO

52 1 53 1 54 1
E10.352 2 E10.353 2 E10.354 2
3 3 3

Type 1 DM Type 1 DM
Type 1 DM
w/PDR, w/PDR,
w/PDR,
w/TRD, w/TRD,
w/TRD,
involving not involving
notes: and Rheg. RD
the macula the macula
R73.03 Prediabetes
O24.415  Gestational diabetes
mellitus in pregnancy,
controlled by oral
hypoglycemic drugs

©2016 American Academy of Ophthalmology All rights reserved

 E11 . 3
RETINOPATHY stage edema laterality

DIABETES 2 mild  1 with 1 right

TYPE 2 3 moderate 9 without 2 left

4 severe 3 bilateral
5 PDR

Retinopathy?

Scribe I  Physician Tip:

E11.9
 I   I   I  Type 2 DM NO YES
without Comp.
No laterality
MILD = microaneurysms only

MODERATE = more than just micro- Proliferative?

aneurysms but less that severe NPDR

SEVERE = Any of the following

(4–2–1 rule) and no signs
of proliferative retinopathy: NO YES 5
• Severe intraretinal hemorrhages
and microaneurysms in each
of four quadrants Macular
Severity?
Edema?
• Definite venous beading
in two or more quadrants

• Moderate IRMA in one

Mild 2 Moderate 3 Severe 4
or more quadrants YES NO

PDR = one or both of the following:

neovascularization or vitreous /
Macular Macular Macular 1 1
pre-retinal hemorrhage Edema? Edema? Edema? E11.351 2 E 1 1 . 359 2
3 3

Type 2 DM Type 2 DM
with Prolif. with Prolif.
YES NO YES NO YES NO
with ME without ME

1 1 1 1 1 1 chart continues
E11.321 2 E11.329 2 E11.331 2 E11.339 2 E11.341 2 E11.349 2
3 3 3 3 3 3

Type 2 DM Type 2 DM Type 2 DM Type 2 DM Type 2 DM Type 2 DM Sev.

Mild with Mild without Mod. with Mod. without Sev. with without
ME ME ME ME ME ME

©2016 American Academy of Ophthalmology All rights reserved

 E11 . 35
PDR stage laterality
DIABETES
TYPE 2 5 2 TRD invol. macula 1 right
5 3 TRD NOT invol. macula 2 left
5 4 comb. TRD & Rheg RD 3 bilateral
5 5 Stable PDR
Proliferative
Retinopathy

Stable see page 1 for

continued from previous page NO RD? NO
PDR? PDR codes

YES

YES

TRD?

55 1
involving and
E11.355 2
the NO Rhegmatogenus YES
3
Macula? RD?

Type 2 DM
w/stable PDR
YES NO

52 1 53 1 54 1
E11.352 2 E11.353 2 E11.354 2
3 3 3

Type 2 DM Type 2 DM
Type 2 DM
w/PDR, w/PDR,
w/PDR,
w/TRD, w/TRD,
w/TRD,
involving not involving
notes: and Rheg. RD
the macula the macula
R73.03 Prediabetes
O24.415  Gestational diabetes
mellitus in pregnancy,
controlled by oral
hypoglycemic drugs

©2016 American Academy of Ophthalmology All rights reserved