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Coding and Documentation of Diabetes Mellitus in ICD-10-CM
ICD-10-CM
When coding a diabetic complication, always remember to state and document any associated conditions using these linking terms โ due to, associated with, secondary to, diabetic โ to establish the causal relationship between the two conditions.
E11.9 Type 2 diabetes mellitus without complications
Z79.4 Long-term (current) use of insulin
E11.21 Type 2 diabetes mellitus with^ diabetic nephropathy^ Type 2 diabetes mellitus with
kidney complications
(use additional code to identify
stage of chronic kidney disease) N18.1โ N18.
(use an additional code for stage 5
or
end stage renal disease on dialysis )
E11.
E11.
Type 2 diabetes mellitus with diabetic chronic kidney disease
๏ Chronic kidney disease, stage 1
N18.
๏ Chronic kidney disease, stage 2 (mild)
N18.
๏ Chronic kidney disease, stage 3 (moderate, unspecified)
N18.3 0
๏ Chronic kidney disease, stage 3A
N18.
๏ Chronic kidney disease, stage 3B
N18.
๏ Chronic kidney disease, stage 4 (severe)
N18.
๏ Chronic kidney disease, stage 5
N18.
๏ End stage renal disease
N18.
๏ Dependence on renal dialysis
Z99.
Type 2 diabetes mellitus with other diabetic kidney complication
*E11.31- Type 2 diabetes mellitus with unspecified diabetic retinopathy Type 2 diabetes with
ophthalmic complications
1 โ with macular edema
9 โ without macular edema
*E11.32-
Type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy
*E11.33-
Type 2 diabetes mellitus with moderate non-proliferative diabetic retinopathy
*E11.34-
Type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy
*E11.35- Type 2 diabetes mellitus with proliferative diabetic retinopathy
*Requires 6th character to identify the complication *Requires 7th character to designate laterality
E11.36 Type 2 diabetes mellitus with diabetic cataract 1 right eye, 2 left eye, 3 bilateral, 9unspecified
E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication
Updated 3/5/
Coding and Documentation of Diabetes Mellitus in ICD-10-CM
ICD-10-CM
When coding a diabetic complication, always remember to state and document any associated conditions using these linking terms โ due to, associated with, secondary to, diabetic โ to establish the causal relationship between the two conditions.
E11.610 Type 2 diabetes mellitus with^ diabetic neuropathic arthropathy
Diabetes with other
specified
complications
E11.618 Type 2 diabetes mellitus with^ other diabetic arthropathy
E11.620 Type 2 diabetes mellitus with^ diabetic dermatitis
E11.
Type 2 diabetes mellitus with foot ulcer ๏ Use additional code to identify site of ulcer (L94.4 -L97.5 )
E11.
Type 2 diabetes mellitus with other skin ulcer ๏ Use additional code to identify site of ulcer (L94.1_-L97.9, L98.41- L98.49)
E11.628 Type 2 diabetes mellitus with other skin complication
E11.630 Type 2 diabetes with^ periodontal disease
E11.638 Type 2 diabetes mellitus with^ other oral complications
E11.641 Type 2 diabetes mellitus with^ hypoglycemia with coma
E11.649 Type 2 diabetes mellitus with^ hypoglycemia without^ coma
E11.65 Type 2 diabetes mellitus with hyperglycemia
E11.
Type 2 diabetes mellitus with other specified complication Use additional code to identify complications (e.g., hyperlipidemia due to DM, use code E11.69 and E78.5 to identify complication of hyperlipidemia or ED secondary to DM E11.69, N52.1)
Diabetes mellitus documentation tips:
- When documenting diabetes, include the following: type 1, or type 2, drug or chemical induces, due to
underlying condition
๏ Complications โ what other body systems are affected by the diabetes condition?
๏ Treatment โ is the patient on insulin? (long-term use of insulin Z79.4)
- Note: assign as many (E11.-) codes as needed to identify all the manifestations/body systems affected.
- Diabetes and complications due to diabetes: a cause-and-effect relationship must be stated to correctly
code a diabetic complication (e.g., due to, associated with, secondary to, diabetic).
- Blood pressure, weight and BMI (every visit): adults with treated or untreated BP> 135/80 mm Hg should
be screened for diabetes.
- Comprehensive dilated eye exam: recommended annually for patients with diabetes
E11.40 Type 2 diabetes mellitus with^ diabetic neuropathy,^ unspecified^ Diabetes with
neurological
complications
E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy
E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy
E11.
Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy โ diabetic gastroparesis
E11.44 Type 2 diabetes mellitus with diabetic amyotrophy
E11.49 Type 2 diabetes mellitus other diabetic neurological complication
E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene Diabetes with
peripheral
circulatory
complications
E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E11.59 Type 2 diabetes mellitus with other circulatory complications
