Find information on diabetes with hyperglycemia diagnosis, including uncontrolled diabetes and poorly controlled diabetes management. This resource covers clinical documentation, medical coding, ICD-10 codes for diabetes with hyperglycemia, and healthcare guidelines for optimal diabetic treatment. Learn about diagnosing and managing high blood sugar in patients with diabetes.
Also known as
Diabetes mellitus
Covers various types of diabetes with hyperglycemia as a key feature.
Diabetes with complications
Includes diabetes with both acute and chronic complications like uncontrolled hyperglycemia.
Hyperglycemia
Specifically designates abnormally high blood glucose levels.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the diabetes type 1?
Yes
Any documentation of uncontrolled/poor control?
No
Is the diabetes type 2?
When to use each related code
| Description |
|---|
| Diabetes with high blood sugar. |
| Diabetes with normal blood sugar. |
| Elevated blood sugar without diabetes. |
Coding diabetes without specifying type (I or II) leads to inaccurate severity and treatment reflection, impacting reimbursement and quality metrics.
Documenting hyperglycemia without specific blood glucose levels or A1C values makes accurate coding challenging and may trigger audits.
Using interchangeable terms like "uncontrolled" and "poorly controlled" without clear clinical indicators can lead to coding inconsistencies and compliance issues.
Q: What are the most effective strategies for managing hyperglycemia in patients with uncontrolled diabetes, considering both short-term and long-term goals?
A: Managing hyperglycemia in uncontrolled diabetes requires a multifaceted approach addressing both immediate glucose control and long-term metabolic health. Short-term strategies include optimizing insulin therapy (basal-bolus or continuous subcutaneous insulin infusion), addressing contributing factors like infections or medications, and patient education on carbohydrate counting and self-monitoring of blood glucose. Long-term strategies focus on lifestyle modifications, including medically supervised weight loss programs, individualized dietary plans emphasizing low-glycemic index foods, and structured exercise regimens. Regular assessment of HbA1c, lipid profile, and microvascular complications is crucial. Consider implementing a collaborative care model involving physicians, nurses, dieticians, and certified diabetes educators to provide comprehensive patient support. Explore how incorporating telehealth and remote patient monitoring can enhance adherence and improve outcomes in uncontrolled diabetes management.
Q: How can clinicians differentiate between poorly controlled diabetes due to medication non-adherence versus other contributing factors, such as insulin resistance or inadequate dosing?
A: Distinguishing between medication non-adherence and other factors contributing to poorly controlled diabetes requires a thorough patient assessment. Begin by openly discussing medication adherence with the patient in a non-judgmental manner. Inquire about their understanding of the treatment plan, ability to afford medications, and any perceived barriers to adherence. Review medication dispensing records and self-monitored blood glucose logs for patterns suggestive of missed doses. Evaluate other potential causes of hyperglycemia, including insulin resistance (assessing C-peptide levels, fasting insulin), inadequate dosing (analyzing insulin-to-carbohydrate ratios and basal insulin requirements), presence of other medical conditions (infections, stress, hormonal imbalances), and medication interactions. Learn more about validated tools for assessing medication adherence and explore strategies to improve patient engagement and shared decision-making in diabetes management.
Patient presents with uncontrolled diabetes mellitus characterized by persistent hyperglycemia. Symptoms include polyuria, polydipsia, polyphagia, and recent weight loss. The patient reports a history of elevated blood glucose levels despite current diabetes management, indicating poorly controlled diabetes. Fasting blood glucose today was [insert value] mg/dL, and HbA1c is [insert value]%, confirming the diagnosis of diabetes with hyperglycemia. Assessment reveals potential complications related to chronic hyperglycemia, including risk for diabetic neuropathy, retinopathy, nephropathy, and cardiovascular disease. The patient's current diabetes treatment regimen includes [list medications, dosages, and frequencies]. Plan of care includes medication adjustment, emphasizing the importance of diabetes self-management education, including blood glucose monitoring, carbohydrate counting, and regular exercise. Dietary counseling will be provided to address nutritional management for optimal glycemic control. Referral to an endocrinologist is recommended for further evaluation and management of uncontrolled diabetes. Follow-up appointment scheduled in two weeks to monitor blood glucose levels and assess treatment efficacy. This documentation supports ICD-10 code E11.9, Type 2 diabetes mellitus without complications, with uncontrolled hyperglycemia. This aligns with medical billing and coding guidelines for diabetes management.