Q: If our physician only documents “uncontrolled diabetes” in an admitted patient’s chart, but I can see from the lab results in the record that the patient’s blood glucose levels are high, can I go ahead and assign the ICD-10-CM code for diabetes with hyperglycemia? Show A: No. Coders cannot assign a diagnosis without the specific documentation from the physician. Although the lab results confirm that the patient’s blood sugar levels are abnormal, we as coders cannot assume a diagnosis for a patient. And regardless, since a code cannot be assigned for uncontrolled diabetes in ICD-10-CM, a query would still need to be submitted to the physician to clarify the exact condition that is being treated. Querying the physician will also ensure that the medical record accurately reflects the patient’s condition, in addition to accurate and specific code assignment, since ICD-10-CM offers many code variations of diabetes and hyperglycemia. Some of these codes include:
Editor’s note: Sarah Humbert, RHIA, AHIMA-certified ICD-10-CM/PCS trainer, coding and compliance manager at KIWI-TEK LLC, and Temeka Davis, RHIT, coding manager at KIWI-TEK LLC, answered this question during HCPro’s webinar Simplify Complex ICD-10-CM Coding for Diabetes. This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment. Need expert advice? Email your questions for consideration in the Revenue Cycle Daily Advisor. Note: We do not guarantee that all questions will be answered. This Coding Tip was updated on 8/12/2022 How do coders report uncontrolled DM in ICD-10-CM?First, coders will need to have further documentation of hyperglycemia or hypoglycemia as there is no default code for uncontrolled diabetes. Uncontrolled diabetes is classified by type and whether it is hyperglycemia or hypoglycemia. The term “uncontrolled” is not synonymous with hyperglycemia. The term “poorly controlled” is synonymous with hyperglycemia when referring to diabetes in ICD-10-CM. In ICD-9-CM, uncontrolled diabetes had a specific 5th digit to show that the diabetes was controlled or uncontrolled. This is no longer the case in ICD-10-CM. If the patient has documented uncontrolled diabetes, without further clarification of hyperglycemia and/or hypoglycemia, a query is necessary to clarify which type the patient has. If the patient does have documented hyperglycemia or hypoglycemia in addition to the diagnosis of uncontrolled diabetes, ICD-10-CM codes would be used to show that the diabetes is with hyperglycemia and/or hypoglycemia. Is uncontrolled and poorly controlled DM the same?No, uncontrolled and poorly controlled are not interchangeable when describing diabetes in ICD-10-CM. Uncontrolled can mean either hyperglycemia or hypoglycemia and is indexed as such in ICD-10-CM. Poorly controlled means hyperglycemia per the ICD-10-CM index. From the ICD-10-CM Index:Diabetes, diabetic (mellitus) (sugar) Diabetes, diabetic (mellitus) (sugar) Please see question and answer in AHA Coding Clinic, First Quarter 2017 Page: 42
ICD-10 Code – E11.65 – Type 2 Diabetes Mellitus with Hyperglycemia ICD-10 code E11.65 represents the appropriate diagnosis code for uncontrolled type 2 diabetes without complications. Clinical documentation must support the following: Elevated glucose (sugar) levels, length of condition, severity of illness, if insulin use is required, and any associated manifestations or underlying chronic diseases. High blood glucose levels in diabetes mellitus are indicative of inadequate or poorly controlled diabetes. Reporting specificity is increasingly important if you participate in an HCC risk adjustment payment model. Clinical documentation must support the complexity of the diagnosis code(s) reported. What is the ICDICD-10 code E11. 65 represents the appropriate diagnosis code for uncontrolled type 2 diabetes without complications.
What is the ICDR73. 9 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2023 edition of ICD-10-CM R73.
How do you code uncontrolled diabetes?Coding guidance
Clinicians typically use the phrase uncontrolled DM to describe a patient whose blood glucose levels are elevated or whose HbA1c is above target.
What is Type 2 diabetes mellitus with hyperglycemia?Type 2 diabetes with hyperglycemia occurs when a person's blood sugar elevates to potentially dangerous levels that require medical treatment. A person living with type 2 diabetes can experience either hyperglycemia, which means an elevated blood glucose level, or hypoglycemia, which refers to a low level.
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Uncontrolled type 2 diabetes mellitus with hyperglycemia icd 10
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