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Documentating Diabetes Mellitus, Hypoglycemia and Hyperglycemia

By:  Find-A-Code
Published:  August 30th, 2016

The Increased Specificity in ICD-10-CM means documentation must more specific to accommodate the complications and combinations used.  

The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system.

When documenting diabetes, include the following:
1.    Type    e.g. Type 1 or Type 2 disease, drug or chemical induces, due to underlying condition, gestational
2.    Complications    What (if any) other body systems are affected by the diabetes condition? e.g. Foot ulcer related to diabetes mellitus
3.    Treatment     Is the patient on insulin?

A second important change is the concept of “hypoglycemia” and “hyperglycemia.” It is now possible to document and code for these conditions without using “diabetes mellitus.” You can also specify if the condition is due to a procedure or other cause.

The final important change is that the concept of “secondary diabetes mellitus” is no longer used; instead, there are specific secondary options.


ICD-10 Code Examples
E08.65    Diabetes mellitus due to underlying condition with hyperglycemia
E09.01    Drug or chemical induced diabetes mellitus with hyperosmolarity with coma
R73.9     Transient post-procedural hyperglycemia
R79.9     Hyperglycemia, unspecified


References:

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