# Diabetes, type 2, uncontrolled for I-10 - coding Diabetes



## asmith79

I am looking for any information on coding Diabetes, Type 2, uncontrolled for ICD 10. In a recent educational discussion there was some confusion on which was the appropriate code to use, E11.9 or E11.65. The thought behind E11.65 is that the terms "uncontrolled" and "out of control" have the same meaning. When you look in the alpha index under diabetes, out of control, ( page 95) , it directs you to code "Diabetes, specificed type, with hyperglycemia" which would take you to E11.65.

During the discussion some argued that the terms "uncontrolled" and "inadequately controlled" or "out of control" did not have the same meaning. Does any one have any documentation supporting or disputing this?

Also, it was brought up that since our chart just said "uncontrolled" how could we use the code E11.65 since it specifically stated hyperglycemia? Is there any documentation out there stating that "uncontrolled" diabetes refers to hyperglycemia?

Anything would be appreciated!

Thanks!!!
Angela Smith CPC, CFPC, COBGC


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## BenCrocker

Found this: http://journal.ahima.org/2012/05/16/coding-diabetes-mellitus-in-icd-10-cm-4/ Apparently ICD 10 doesn't use the term UNCRONTROLLED anymore. It's either inadequately controlled, Out of control, or Poorly controlled.


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## mitchellde

BenCrocker said:


> Found this: http://journal.ahima.org/2012/05/16/coding-diabetes-mellitus-in-icd-10-cm-4/ Apparently ICD 10 doesn't use the term UNCRONTROLLED anymore. It's either inadequately controlled, Out of control, or Poorly controlled.



The problem I have with articles like this is that this is someone's version or opinion and they wrote an article.  At no time is an official source cited for that statement.  I agree that diabetes with hyperglycemia is an out of control disease process, however I do not agree that just because the provider documents "uncontrolled", that this is always what they are referencing.  In other words a diabetic patient that does not always adhere to proper diet or does not take the insulin correctly, while they may not yet be hyperglycemic, the provider may document the diabetes is poorly controlled.  The coding guidelines do not direct us to code uncontrolled status as diabetes with hyperglycemia.  And the classification does not have a listing for diabetes, uncontrolled, or uncontrolled, diabetes.  Without an official source, I will default to , if the provider does not state diabetes with hyperglycemia, then it cannot be coded that way.
Another point to consider on this, an endocrinologist once told me that the reason the ICD-9 classification choices state, uncontrolled, or not stated as uncontrolled instead of uncontrolled vs controlled, is that diabetes is truly never in a "controlled" state and the reason this is not stated this way in ICD-10 CM is because the physician does not need to document this, it is understood that the reason we monitor the diabetic patient as closely as we do is because they are never truly under control.  He had a lot more to say on this subject and it does make sense.
  So I would hesitate to put stock in an article that makes a bold statement but does not back it up.


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## BenCrocker

So AHIMA is not a reputable sourse of coding information given a CCS is comparable to AAPCs CPC?


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## mitchellde

BenCrocker said:


> So AHIMA is not a reputable sourse of coding information given a CCS is comparable to AAPCs CPC?



That is not what I said.  This was an article written by a person, that offered no official source for their information.
The article states:
Diabetes mellitus codes are no longer classified as controlled or uncontrolled. Instead ICD-10-CM classifies inadequately controlled, out of control, and poorly controlled diabetes mellitus by type with hyperglycemia.

However there is no corroboration with any resource.  The ICD-10 CM classification does not make this statement at all.  You are given a choice of a code for diabetes with hyperglycemia, or diabetes with hypoglycemia.  However at no time is there a reference in the classification that directs the coder to coded uncontrolled diabetes with either of these choices.  
When you look up uncontrolled diabetes the results are all over the place and there is no overwhelming agreement that uncontrolled is in fact hyperglycemia.  Therefore until the guidelines or the classification directs us that uncontrolled diabetes and hyperglycemia are interchangeable terms, then I must believe that the provider needs to document the hyperglycemia explicitly.


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## BenCrocker

So ICD-10-CM guidelines need to be clearer. I agree with you.
I reread my I-10-Cm draft and you're right, I can't even find Inadequately, Out of, or Poorly Controlled used at all. 

My apologies.

Guidelines state that if there is no documentation as to the type it defaults to E11.- Type 2.
No where does it care about the control just that it "is" and the body system affected and complications.
Complications does not include control but are more concerned about insulin over/under doses and other things I'm sure.


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## mitchellde

BenCrocker said:


> So ICD-10-CM guidelines need to be clearer. I agree with you.
> I reread my I-10-Cm draft and you're right, I can't even find Inadequately, Out of, or Poorly Controlled used at all.
> 
> My apologies.
> 
> Guidelines state that if there is no documentation as to the type it defaults to E11.- Type 2.
> No where does it care about the control just that it "is" and the body system affected and complications.
> Complications does not include control.



That was my point exactly.  Thank you for agreeing.


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## BenCrocker

Makes me wonder what information they were reading to come to that conclusion.

And I just looked at all the Cited works and not one of them uses those terms. It's clearly an opinion.


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## mitchellde

BenCrocker said:


> Makes me wonder what information they were reading to come to that conclusion.
> 
> And I just looked at all the Cited works and not one of them uses those terms. It's clearly an opinion.



Exactly!  And there is another post on this exact same issue where I have tried to make this same point.  This is why when people attend seminars and read articles they receive information that sometimes is just an opinion being past on as authoritative information with no source for back up.  I teach seminars and I hear this kind of thing all the time.  All I can ask is did that person provide back up for what was stated.  Most times the response is no.


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## asmith79

Thank you both very much for your input on this subject. It is much appreciated and helps clear up some confusion I had on it! I think those creating and working on the ICD-10 code have a lot of work ahead of them fine tuning the codes. 

Angela Smith , CPC, CFPC, COBGC


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## Creme

The 2016 AHA Coding Handbook gives this example in a practice question:
Question:  uncontrolled type 2 diabetes mellitus      
Answer: E33.65 DM2 w/hyperglycemia


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## Creme

that should read: E11.65


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## CBondurant1226

*Uncontrolled Diabetes AHA Coding Clinic 2017*

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.
Answer:
There is no default code for "uncontrolled diabetes." Effective October 1, 2016, uncontrolled diabetes is classified by type and whether it is hyperglycemia or hypoglycemia. If the documentation is not clear, query the provider for clarification whether the patient has hyperglycemia or hypoglycemia so that the appropriate code may be reported; uncontrolled diabetes indicates that the patient's blood sugar is not at an acceptable level, because it is either too high or too low. In the ICD-10-CM Index to Diseases, uncontrolled diabetes can be referenced as follows:
Diabetes, diabetic (mellitus) (sugar)
Uncontrolled meaning
hyperglycemia - see Diabetes, by type, with hyperglycemia
hypoglycemia - see Diabetes, by type, with hypoglycemia


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## chaimz

mitchellde said:


> The problem I have with articles like this is that this is someone's version or opinion and they wrote an article.  At no time is an official source cited for that statement.  I agree that diabetes with hyperglycemia is an out of control disease process, however I do not agree that just because the provider documents "uncontrolled", that this is always what they are referencing.  In other words a diabetic patient that does not always adhere to proper diet or does not take the insulin correctly, while they may not yet be hyperglycemic, the provider may document the diabetes is poorly controlled.  The coding guidelines do not direct us to code uncontrolled status as diabetes with hyperglycemia.  And the classification does not have a listing for diabetes, uncontrolled, or uncontrolled, diabetes.  Without an official source, I will default to , if the provider does not state diabetes with hyperglycemia, then it cannot be coded that way.
> Another point to consider on this, an endocrinologist once told me that the reason the ICD-9 classification choices state, uncontrolled, or not stated as uncontrolled instead of uncontrolled vs controlled, is that diabetes is truly never in a "controlled" state and the reason this is not stated this way in ICD-10 CM is because the physician does not need to document this, it is understood that the reason we monitor the diabetic patient as closely as we do is because they are never truly under control.  He had a lot more to say on this subject and it does make sense.
> So I would hesitate to put stock in an article that makes a bold statement but does not back it up.




I 100% agree with Mitchellde.

If you look in the index under Diabetes Mellitus Type II, under "Uncontrolled" it states "meaning" and under that it says "Hyperglycemia - see Diabetes, by type, with Hyperglycemia. Same thing goes for Hypoglycemia. the index will lead you to either E11.65, or E11.649.  "Uncontrolled" by itself is meaningless in ICD-10-CM. The doctor MUST specify DM Type II WITH Hypoglycemia or Hyperglycemia. Otherwise you down-code it to E11.9.


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## ninadette

*Diabetes, uncontrolled, out of control, poorly controlled, inadequately controlled*



mitchellde said:


> The problem I have with articles like this is that this is someone's version or opinion and they wrote an article.  At no time is an official source cited for that statement.  I agree that diabetes with hyperglycemia is an out of control disease process, however I do not agree that just because the provider documents "uncontrolled", that this is always what they are referencing.  In other words a diabetic patient that does not always adhere to proper diet or does not take the insulin correctly, while they may not yet be hyperglycemic, the provider may document the diabetes is poorly controlled.  The coding guidelines do not direct us to code uncontrolled status as diabetes with hyperglycemia.  And the classification does not have a listing for diabetes, uncontrolled, or uncontrolled, diabetes.  Without an official source, I will default to , if the provider does not state diabetes with hyperglycemia, then it cannot be coded that way.
> Another point to consider on this, an endocrinologist once told me that the reason the ICD-9 classification choices state, uncontrolled, or not stated as uncontrolled instead of uncontrolled vs controlled, is that diabetes is truly never in a "controlled" state and the reason this is not stated this way in ICD-10 CM is because the physician does not need to document this, it is understood that the reason we monitor the diabetic patient as closely as we do is because they are never truly under control.  He had a lot more to say on this subject and it does make sense.
> So I would hesitate to put stock in an article that makes a bold statement but does not back it up.





Folks, the author of this article is precisely correct in their statement that "Instead ICD-10-CM classifies inadequately controlled, out of control, and poorly controlled diabetes mellitus by type with hyperglycemia" (i.e. should be coded as Diabetes with hyperglycemia [type I or II if specified].  The oversight that many coders are making leading to misunderstanding is that they are jumping straight to the sub-term "uncontrolled" (which is synonymous now with out of control, poorly controlled and inadequately controlled) and getting confused by the vague breakdown of Diabetes with hyperglycemia vs. the separately listed sub-term for hypoglycemia.  Because of that coders appear to be overlooking the most specific indexing instructions appearing under the main term "Diabetes, diabetic" itself. 

Look beneath that main term (meaning, prior to the sub-terms for Type I and II) and you will note that the sub-terms and coding instructions for the following various control descriptions are clearly stated: "inadequately controlled - code to Diabetes, by type, with hyperglycemia"; "out of control - code to Diabetes, by type, with hyperglycemia"; and "poorly controlled - code to Diabetes, by type, with hyperglycemia". 

Therefore, AHIMA's Journal article instructions are indeed correct that (notwithstanding a physician clearly stipulating hypoglycemia as the issue), the correct code for the above uncontrolled/out of control/poorly controlled/inadequately controlled statuses is Diabetes with hyperglycemia (with Type if known).


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