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ICD-10 Coding for Type 2 Diabetes with Hyperglycemia(E11.65)

Complete ICD-10-CM coding and documentation guide for Type 2 Diabetes with Hyperglycemia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Type 2 Diabetes Mellitus with HyperglycemiaT2DM with Hyperglycemia

Related ICD-10 Code Ranges

Complete code families applicable to Type 2 Diabetes with Hyperglycemia

E11.0-E11.9Primary Range

Type 2 diabetes mellitus

This range includes all codes related to type 2 diabetes mellitus, including specific complications such as hyperglycemia.

Key Information: ICD-10 code for type 2 diabetes with hyperglycemia

Essential facts and insights about Type 2 Diabetes with Hyperglycemia

The ICD-10 code for type 2 diabetes with hyperglycemia is E11.65, requiring documented hyperglycemia.

Primary ICD-10-CM Code for type 2 diabetes with hyperglycemia

Type 2 diabetes mellitus with hyperglycemia
Billable Code

Decision Criteria

clinical Criteria

  • Documented fasting glucose ≥126 mg/dL or random glucose ≥200 mg/dL with symptoms

documentation Criteria

  • Include specific glucose levels and symptoms in the patient's record

Applicable To

  • Type 2 diabetes with hyperglycemia

Excludes

  • Type 1 diabetes mellitus with hyperglycemia (E10.65)

Clinical Validation Requirements

  • Fasting glucose ≥126 mg/dL
  • Random glucose ≥200 mg/dL with symptoms
  • HbA1c ≥6.5% with documented hyperglycemia symptoms

Code-Specific Risks

  • Incorrectly coding without evidence of hyperglycemia
  • Omitting necessary ancillary codes like Z79.4 for insulin use

Coding Notes

  • Ensure documentation includes specific glucose levels and symptoms to support hyperglycemia coding.

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Long-term (current) use of insulin

Z79.4
Use when the patient is on long-term insulin therapy.

Long-term (current) use of oral hypoglycemic drugs

Z79.84
Use for patients on oral hypoglycemic agents.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Type 2 diabetes mellitus without complications

E11.9
Use E11.9 when there is no evidence of hyperglycemia or other complications.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Type 2 Diabetes with Hyperglycemia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code E11.65.

Impact

Clinical: Misrepresentation of patient's condition., Regulatory: Potential audit issues., Financial: Claim denials due to incorrect coding.

Mitigation Strategy

Verify glucose levels are documented before coding.

Impact

Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records and data reporting.

Mitigation Strategy

Ensure hyperglycemia is documented with specific glucose levels or symptoms.

Impact

Lack of specific glucose documentation can trigger audits.

Mitigation Strategy

Ensure all glucose levels and symptoms are documented.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for Type 2 Diabetes with Hyperglycemia, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Type 2 Diabetes with Hyperglycemia

Use these documentation templates to ensure complete and accurate documentation for Type 2 Diabetes with Hyperglycemia. These templates include all required elements for proper coding and billing.

Outpatient Visit for Type 2 Diabetes with Hyperglycemia

Specialty: Endocrinology

Required Elements

  • Patient's glucose levels
  • Symptoms of hyperglycemia
  • Current treatment plan

Example Documentation

Patient presents with fasting glucose of 150 mg/dL and increased thirst. Plan includes adjusting metformin dosage.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Diabetes uncontrolled.
Good Documentation Example
Type 2 diabetes with hyperglycemia; fasting glucose 210 mg/dL, increased thirst.
Explanation
The good example provides specific glucose levels and symptoms, supporting the hyperglycemia diagnosis.

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