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This the 1 last update 05 Jun 2020 Coding Tip was updated on 12/10/2018This Coding Tip was updated on 12/10/2018

Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer

How do coders report uncontrolled DM in ICD-10-CM?

First, coders will need to have further documentation of hyperglycemia or hypoglycemia as there is no default code for uncontrolled diabetes. Uncontrolled diabetes is classified by type and whether it is hyperglycemia or hypoglycemia.

The term “uncontrolled” is not synonymous for 1 last update 05 Jun 2020 with hyperglycemia. The term “poorly controlled” is synonymous with hyperglycemia when referring to diabetes in ICD-10-CM.The term “uncontrolled” is not synonymous with hyperglycemia. The term “poorly controlled” is synonymous with hyperglycemia when referring to diabetes in ICD-10-CM.

In ICD-9-CM, uncontrolled diabetes had a specific 5th digit to show that the diabetes was controlled or uncontrolled. This is no longer the case in ICD-10-CM.  If the patient has documented uncontrolled diabetes, without further clarification of hyperglycemia and/or hypoglycemia, a query is necessary to clarify which type the patient has. If the patient does have documented hyperglycemia or hypoglycemia in addition to the diagnosis of uncontrolled diabetes, ICD-10-CM codes would be used to show that the diabetes is with hyperglycemia and/or hypoglycemia.

Is uncontrolled and poorly controlled DM the same?

No, uncontrolled and poorly controlled are not interchangeable when describing diabetes in ICD-10-CM.  Uncontrolled can mean either hyperglycemia or hypoglycemia and is indexed as such in ICD-10-CM. Poorly controlled means hyperglycemia per the ICD-10-CM index.

From the ICD-10-CM Index:

Diabetes, diabetic (mellitus) (sugar)
Poorly controlled-code to Diabetes, by type with hyperglycemia

Diabetes, diabetic (mellitus) (sugar)
Meaning
Hyperglycemia-see Diabetes, by type, with hyperglycemia
Hypoglycemia-see Diabetes, by type, with hypoglycemia

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The information contained in this coding the 1 last update 05 Jun 2020 advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

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