Clinical validation of diabetic ketoacidosis (DKA) requires more than recognizing symptoms—it demands a clear understanding of diagnostic criteria, interpretation of lab results, and provider documentation. For CDI specialists and coding professionals, distinguishing true DKA from euglycemic presentations is critical to ensuring accurate code assignment and compliant reporting.
In this article, we break down the American Diabetes Association (ADA) diagnostic criteria for DKA and euglycemic DKA, highlight key clinical indicators, and walk through real-world scenarios to support defensible documentation and coding decisions.
Diabetes Mellitus (DM) is a metabolic disorder characterized by high levels of glucose in the blood. Glucose is a simple sugar produced by the body, but it can also come from food, and it is the main source of energy for the cells in the body. The pancreas produces hormones that have opposite effects (antagonist hormones) that work together to regulate blood sugar levels and maintain balance. Without this balance, diabetes mellitus can develop and progress into serious complications affecting blood vessels, nerves, kidneys, eyes, and skin. These pancreatic hormones are insulin and glucagon.
Insulin: Produced by beta cells after meals when sugar levels are high. It lowers high sugar levels by allowing glucose to enter cells to be used as energy, and what is not used is stored as glycogen.
Glucagon: Produced by alpha cells during a fasting state when sugar levels are low. Glucagon raises sugar levels by signaling the liver to break down stored glycogen into glucose to be used as energy.
Diabetes develops due to either primary or secondary causes.
Primary causes: Type 1 DM (autoimmune), Type 2 DM (insulin resistance), and Gestational Diabetes (hormonal changes during pregnancy that resolve after childbirth).
Secondary causes: Medications (steroids, statins), toxins (pesticides, pollutants), or disease processes (pancreatitis, cystic fibrosis, pancreatic malignancy, polycystic ovary syndrome).
This article focuses on primary causes of diabetes, including:
Type 1 Diabetes, sometimes called juvenile diabetes, is an autoimmune disease usually diagnosed before the age of 18. The immune system mistakenly sees beta cells as foreign and destroys them. When enough beta cells are destroyed, the pancreas is no longer able to produce insulin.
Symptoms: Frequent urination, excessive thirst, unsatiable hunger, fatigue, blurry vision, slow healing of cuts, and weight loss.
Treatment: Insulin therapy.
Type 2 Diabetes is characterized by insulin resistance and pancreatic hormone failure. Fat and muscle cells stop responding to insulin, so it takes more and more insulin for cells to take in glucose and convert it into energy. Beta cells work overtime to compensate for this imbalance. Eventually, the body builds a tolerance until the beta cells wear out and are not able to produce enough insulin to overcome the resistance, causing elevated blood glucose.
Symptoms: Frequent urination, excessive thirst, unsatiable hunger, fatigue, blurry vision, slow healing of cuts, numbness and/or tingling of extremities.
Treatment: Diet, exercise, oral medication, and sometimes insulin therapy.
The American Diabetes Association (ADA) is a health organization founded in the 1940s to conduct research and education on diabetes.They have developed the ADA Standards of Care in Diabetes, which are diagnostic criteria for diagnosing diabetes and diabetic complications, including diabetic ketoacidosis.
Diabetic ketoacidosis is a serious complication of Type 1 and Type 2 DM characterized by fruity smelling breath, extreme thirst, vomiting, hyperglycemia, dehydration, and altered mental status. When the body lacks insulin, cells cannot take in glucose to convert into energy. The liver is then forced to burn fat for energy, producing ketones. Overproduction of ketones can make the blood dangerously acidic, causing DKA.
Symptoms: Excessive thirst, fruity smelling breath, vomiting, confusion.
Treatment: IV fluids and insulin drip.
Clinical validation of DKA under the ADA diagnostic criteria requires documentation of all of the following:
Euglycemic diabetic ketoacidosis is differentiated from DKA by a blood glucose level of less than 250 mg/dL. Factors that trigger lower blood sugar levels despite insulin deficiency include nutritional stress (fasting, low-carb diet, anorexia), illness (sepsis, UTI), or medications (SGLT2 inhibitors such as Jardiance). The body still cannot move glucose into cells, so the liver burns fat for energy, causing ketone acidosis.
Clinical validation of e-DKA under the ADA diagnostic criteria requires documentation of all of the DKA criteria except:
A medical record analysis for confirmation of diagnostic criteria for DKA and e-DKA includes reviewing practitioner notes, lab reports, and medication administration records. Finding relevant documentation is aided by searching for terms such as fruity smelling breath, nausea, excessive thirst, confusion, and/or comatose state in the progress notes.
Pertinent lab results can be found in various places in the electronic health record (EHR):
Treatment may include hospital admission for electrolyte infusion, IV fluids, and insulin drip.
If diagnostic criteria do not meet all of the required measures for diabetic ketoacidosis, this does not necessarily mean the patient does not have the condition. Laboratory blood work may have been drawn after insulin drip administration, masking the signs and symptoms. DKA and e-DKA are coded based on the type of diabetes and the presence of coma. CDI will query the provider to clarify conflicting, incomplete, or missing documentation.
Per the ICD-10-CM Official Guidelines for Coding and Reporting FY 2026: The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists.
The following case studies illustrate clinical validation of diabetic ketoacidosis from a CDI perspective.
SCENARIO 1
H&P: 21-year-old female with history of Type 1 DM presented with fruit-scented breath, nausea, vomiting, and a blood glucose of 320. Differential diagnoses included dehydration and Type 1 DM with hyperglycemia. ABGs, BMP including BHB, and UA were ordered. Concern for DKA; LR bolus initiated. DS: Admitted with dehydration, nausea, and vomiting. ABGs confirmed acidosis with low pH and bicarbonate, and B-hydroxybutyrate of 3.7. Blood glucose of 167 upon discharge. Nausea, vomiting, hyperglycemia, and DKA resolved. Patient educated on signs and symptoms of DKA and advised to seek immediate medical attention if symptoms return. Clinical Indicators: Fruity smelling breath, vomiting
Treatment: Blood sugar monitoring every 2 hours, insulin drip Can CDI code the diagnosis of DKA using the diagnostic criteria? Yes. This scenario meets the DKA criteria.
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SCENARIO 2
H&P: 49-year-old female with history of CKD, chronic diastolic heart failure, and Type 2 DM presented with anorexia, nausea, and extreme fatigue. Family reported fruity smelling breath, blood sugar of 158 on a home glucometer, and trouble following simple commands. Neuro checks every 4 hours were ordered, along with ABGs, BMP, BHB, and urinalysis. ABGs showed pH 7.21, pCO2 37, and HCO3 12. LR initiated. Patient admitted to ICU and insulin drip started for Type 2 DKA with confusion. DS: Type 2 DM with nausea and DKA without coma resolved; mental status returned to baseline. Upon discharge, repeat ABGs showed pH 7.36, pCO2 37, HCO3 24, glucose down-trending, and repeat urinalysis negative for ketones. Discharged home in stable condition and instructed to continue Jardiance as ordered. Clinical Indicators: Fruity smelling breath, extreme fatigue, confusion
Treatment: ICU bed, blood sugar monitoring every 2 hours, insulin drip Can CDI code the diagnosis of DKA using the diagnostic criteria? No. This scenario does not meet DKA criteria.
Can CDI code the diagnosis of euglycemic diabetic ketoacidosis (e-DKA) using the diagnostic criteria? No. This scenario does not meet e-DKA diagnostic criteria as documented.
Query OpportunitiesScenario 2 presents an opportunity to query because the clinical indicators meet criteria for e-DKA, but the documentation states only DKA.
Query SampleDear Dr. Sample, We are seeking clarification for documentation of ketoacidosis. 49-year-old female presented with nausea, extreme fatigue, and confusion. H&P (Dr. Sample): Admit patient to ICU, initiate insulin drip for Type 2 diabetic ketoacidosis with confusion. DS (Dr. Sample): Type 2 DM with nausea and DKA without coma resolved; mental status returned to baseline. Clinical Indicators:
Treatment: ICU bed, blood sugar monitoring every 2 hours, LR infusion at 100 ml/min, insulin drip Based upon the clinical indicators listed above, please clarify the diagnosis of ketoacidosis as:
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The American Diabetes Association (ADA) Diagnostic Criteria is a guide to recognizing the clinical indicators of diabetic ketoacidosis. It is an important reference for CDI specialists when reviewing documentation for diabetic patients.
It is important to remember that the assignment of diagnoses is based on the provider’s statement that the condition exists. CDI can query the provider to clarify missing, conflicting, or vague documentation.
References
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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.