AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2017 Issue 1; Ask the Editor
Uncontrolled Diabetes Mellitus
How is uncontrolled diabetes mellitus (DM) coded in ICD-10-CM? Is uncontrolled the same as “poorly controlled” or “out of control? Currently, only “out of control” and “poorly controlled” diabetes mellitus are coded as diabetes with hyperglycemia. ...
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Article Overview
This article discusses ICD-10-CM guidance for documenting and classifying uncontrolled diabetes mellitus, including how related terms are treated and why clarification may be needed when the record is not specific. It is intended for coders, CDI staff, and other revenue-cycle professionals who work with diabetes documentation and diagnosis coding.
Why This Topic Matters
Accurate diabetes documentation affects diagnosis coding consistency and helps prevent misclassification when the record uses nonspecific control-related terminology. The article is relevant because it focuses on how ICD-10-CM indexing and provider clarification intersect for this common condition.
What You Will Learn
- How ICD-10-CM handles documentation of uncontrolled diabetes mellitus
- How common documentation terms related to diabetes control are interpreted
- Why provider clarification may be needed when the record does not specify the type of imbalance
- How the ICD-10-CM index supports lookup of uncontrolled diabetes documentation
Who Should Read This
- Medical coders
- Clinical documentation integrity specialists
- Revenue cycle staff
- Health information management professionals
- Billing staff
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