Q&A: Type 2 diabetes mellitus

Q: A patient is diagnosed with neuropathy due to poorly controlled insulin dependent type 2 diabetes mellitus. What codes should be reported?

A: In this scenario, ICD-10-CM codes E11.40, E11.65, and Z79.4 should be reported.

First, look at the Alphabetic Index. It is easiest to start with the main term “Diabetes” and the modifying term “type 2” and then the sub-term “neuropathy,” which leads to code E11.40.

The question indicates the patient has “poorly controlled type 2 diabetes mellitus.” This statement would be classified as hyperglycemia. Under the main term “Diabetes” and modifying term “poorly controlled” the instructional note says to assign by type with hyperglycemia, which is assigned to E11.65.

Lastly, the patient was also identified as being insulin dependent. The instructional note at the E11 category states to use an additional code of Z79.4 to identify the use of insulin.

The American Hospital Association’s Coding Clinic (3Q, 2013) addressed the issue of poorly controlled diabetes mellitus in its 2013 third quarter edition. It indicated that a separate code should be assigned to identify if the diabetes mellitus is poorly controlled. Any combination of diabetes codes can be assigned together unless one is inherent in the other, such as if a patient had ketoacidosis and uncontrolled diabetes. In that case, you would only code the ketoacidosis because it would be somewhat redundant to say that the patient also had hyperglycemia if they had ketoacidosis.

Editor’s note: This article originally appeared on JustCoding. This information was excerpted from HCPro’s eLearning course “ICD-10-CM Diagnosis Coding for Hospital Outpatient Services.”