Q&A: Assigning ICD-10-CM diabetes codes from lab results

May 17, 2019
Medicare Web

Q: If our physician only documents “uncontrolled diabetes” in an admitted patient’s chart, but I can see from the lab results in the record that the patient’s blood glucose levels are high, can I go ahead and assign the ICD-10-CM code for diabetes with hyperglycemia?

A: No. Coders cannot assign a diagnosis without the specific documentation from the physician. 

Although the lab results confirm that the patient’s blood sugar levels are abnormal, we as coders cannot assume a diagnosis for a patient. And regardless, since a code cannot be assigned for uncontrolled diabetes in ICD-10-CM, a query would still need to be submitted to the physician to clarify the exact condition that is being treated.  

Querying the physician will also ensure that the medical record accurately reflects the patient’s condition, in addition to accurate and specific code assignment, since ICD-10-CM offers many code variations of diabetes and hyperglycemia. Some of these codes include:

  • E09.65, drug or chemical induced diabetes mellitus with hyperglycemia 
  • E10.65, Type 1 diabetes mellitus with hyperglycemia      
  • E11.65, Type 2 diabetes mellitus with hyperglycemia      
  • E13.65, other specified diabetes mellitus with hyperglycemia     
  • E08.65, diabetes mellitus due to underlying condition with hyperglycemia

Editor’s note: Sarah Humbert, RHIA, AHIMA-certified ICD-10-CM/PCS trainer, coding and compliance manager at KIWI-TEK LLC, and Temeka Davis, RHIT, coding manager at KIWI-TEK LLC, answered this question during HCPro’s webinar Simplify Complex ICD-10-CM Coding for Diabetes.

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

Need expert advice? Email your questions for consideration in the Revenue Cycle Daily Advisor. Note: We do not guarantee that all questions will be answered.

Related Topics: 
Ask the Expert