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 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) Uncontrolled Meaning Hyperglycemia-see Diabetes, by type, with hyperglycemia Hypoglycemia-see Diabetes, by type, with hypoglycemia
Please see question and answer in AHA Coding Clinic, First Quarter 2017 Page: 42
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