Type 2 diab with prolif diab rtnop with macular edema, unsp

This code signifies a patient diagnosed with type 2 diabetes who has developed proliferative diabetic retinopathy, a severe form of diabetic eye disease characterized by new, abnormal blood vessel growth on the retina. Crucially, the patient also presents with macular edema, swelling in the macula region of the retina, which is a common cause of vision loss in diabetic retinopathy. The specific eye affected is not documented.

Use this code when the medical record explicitly states a diagnosis of type 2 diabetes mellitus, proliferative diabetic retinopathy, and macular edema, but does not specify whether the condition affects the right, left, or both eyes. Documentation should clearly indicate the presence of all three components: type 2 diabetes, proliferative retinopathy, and macular edema.

• Ensure documentation specifies "proliferative" retinopathy, not just "nonproliferative," and confirms the presence of macular edema.
• If the affected eye (right, left, or bilateral) is documented, a more specific code (E11.3511, E11.3512, E11.3513) should be used instead.
• Always sequence the diabetes code first, as it is the underlying systemic condition causing the retinopathy.