CPT (Current Procedural Terminology) codes are five-digit numeric codes used to describe medical, surgical, and diagnostic services. They are maintained by the American Medical Association and used by healthcare providers, insurers, and Medicare for billing and reimbursement.

What is the difference between facility and non-facility rates?

Non-facility (office) rates are what Medicare pays when a service is performed in a physician's office. Facility rates are lower because when a service is performed in a hospital or ambulatory surgery center, the facility bills separately for overhead costs like equipment and supplies.

RVU stands for Relative Value Unit. Medicare uses RVUs to measure the value of physician services based on three components: physician work, practice expense, and malpractice cost. Total RVUs are multiplied by the conversion factor ($33.40 in 2026) to calculate the Medicare payment amount.

Is E11.3212 a billable ICD-10-CM code?

Yes. E11.3212 (Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye) is a billable/specific ICD-10-CM code and can be reported on a claim when the documentation supports it.

What HCC does E11.3212 map to?

E11.3212 maps to HCC298 (Severe Diabetic Eye Disease, Retinal Vein Occlusion, and Vitreous Hemorrhage); HCC37 (Diabetes with Chronic Complications) in the CMS-HCC V28 risk-adjustment model (Medicare Advantage / Part C) for payment year 2026. Risk-adjustable diagnoses must be documented and resubmitted each year — and survive the CMS-HCC hierarchy and edits — to count toward a member's risk score.

ICD-10-CM · E00–E89BillableHCC298HCC37

ICD-10-CM Code E11.3212

Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye

Source: CMS ICD-10-CM FY2026Effective October 1, 2025Reviewed by the D3rx Clinical Billing Team

Diagnosis information

Billable

Yes

Valid for claim submission

Chapter

E00–E89

Endocrine, nutritional and metabolic diseases

Risk adjustment

HCC

HCC298, HCC37

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HCC risk adjustment (CMS-HCC V28)

HCC298Severe Diabetic Eye Disease, Retinal Vein Occlusion, and Vitreous Hemorrhage

Model CMS-HCC V28Payment year 2026

HCC37Diabetes with Chronic Complications

Model CMS-HCC V28Payment year 2026

In CMS's Hierarchical Condition Category (HCC) model — the risk-adjustment model for Medicare Advantage (Part C) — a documented and submitted E11.3212 may contribute to a member's risk score (subject to the CMS-HCC hierarchy and edits), which helps drive the plan's capitated payment for that patient. To count, the diagnosis must be supported to the MEAT standard (Monitored, Evaluated, Assessed, Treated) and reported on an eligible face-to-face encounter at least once each calendar year — risk scores reset annually.

More codes in the E11 category

Other billable ICD-10-CM codes in the same category as E11.3212. Coding to the highest specificity the documentation supports is what keeps a claim clean — pick the child code that most precisely matches the diagnosis.

E11.00Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E11.01Type 2 diabetes mellitus with hyperosmolarity with coma
E11.10Type 2 diabetes mellitus with ketoacidosis without coma
E11.11Type 2 diabetes mellitus with ketoacidosis with coma
E11.21Type 2 diabetes mellitus with diabetic nephropathy
E11.22Type 2 diabetes mellitus with diabetic chronic kidney disease
E11.29Type 2 diabetes mellitus with other diabetic kidney complication
E11.311Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.319Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E11.3211Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E11.3213Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3219Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye

Documentation & coding notes

E11.3212 is a billable/specific ICD-10-CM code — it can be reported as a primary or secondary diagnosis when the documentation supports it. Code to the highest level of specificity the record allows.
E11.3212 is risk-adjustable: it maps to HCC298, HCC37 in the CMS-HCC V28 model (payment year 2026), the risk-adjustment model for Medicare Advantage (Part C). For the diagnosis to contribute to a member's risk score it must survive the CMS-HCC hierarchy and edits, be documented to the MEAT standard (Monitored, Evaluated, Assessed, Treated), and be submitted on an eligible face-to-face encounter at least once per calendar year.
E11.3212 specifies laterality. Confirm the documented side matches the code — a laterality mismatch between the note and the claim is a frequent denial and audit target.
Always verify the code against the current ICD-10-CM Official Guidelines and the payer's coverage policy before submitting — coverage, medical necessity edits, and sequencing rules vary by payer.

Related E00–E89 codes

E11.9 E78.5 E66.9 E11.65 E11.22 E66.01 E03.9 E55.9

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Medical coding disclaimer

ICD-10-CM codes and descriptions shown are from the CMS FY2026 official code set and HCC mappings from the CMS-HCC V28 model (payment year 2026), shown for educational reference. Official Guidelines, payer coverage, medical-necessity edits, and sequencing rules vary. Always verify with the current ICD-10-CM Official Guidelines and the payer before submitting claims. D3rx is not responsible for coding or billing outcomes.