Primary Care Coding Alert

Question: Our provider documented that a type 2 diabetic patient’s condition was “unstable” but “improving,” as his HbA1c level had fallen to 8.8 from 9.2. One of my colleagues believes I should code this as type 2 with complications because of the provider’s use of the word “unstable,” but I am reluctant to do that or to code something like E11.65. What would be the best code to use in this scenario?

Arkansas Subscriber

Answer: In a sense, all patients with diabetes have unstable hemoglobin levels, which can be regarded as some form of complication. However, you should avoid coding E11.65 (Type 2 diabetes mellitus with hyperglycemia), because that cannot be determined from the patient’s HbA1c level and because you did not state your provider had documented hyperglycemia.

In fact, hyperglycemia should be regarded as a symptom rather than a complication. This means you should rule out such code choices as E11.8 (Type 2 diabetes mellitus with unspecified complications) or E11.69 (Type 2 diabetes mellitus with other specified complication) unless your provider has documented such conditions.

So, in the absence of provider documentation of complications, your best choice, unless directed otherwise by that provider, would be E11.9 (Type 2 diabetes mellitus without complications) with an additional code to identify control using insulin (Z79.4) or either oral antidiabetic or oral hypoglycemic drugs (Z79.84) per ICD-10 guidelines.