Understanding hyperglycemia diagnosis, documentation, and medical coding is crucial for effective patient care. Learn about blood glucose levels, A1C testing, ICD-10 codes for hyperglycemia (E10-E14), diabetes mellitus type 1 and type 2 management, and clinical documentation improvement for accurate reimbursement. This resource provides essential information for healthcare professionals, including physicians, nurses, and medical coders, seeking guidance on hyperglycemia diagnosis, treatment, and proper coding practices. Explore the differences between hyperglycemia and hypoglycemia, as well as the long-term complications and management strategies for optimal patient outcomes.
Also known as
Diabetes mellitus
Hyperglycemia is a key feature of diabetes mellitus.
Hyperglycemia
This code specifically represents abnormal high blood sugar.
Diabetes mellitus in pregnancy
Gestational diabetes involves hyperglycemia during pregnancy.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is hyperglycemia due to diabetes?
Yes
Type 1 diabetes?
No
Is there a documented cause?
When to use each related code
| Description |
|---|
| High blood sugar |
| Diabetic ketoacidosis |
| Hyperosmolar hyperglycemic state |
Coding E11.9 (Unspecified diabetes mellitus with hyperglycemia) without proper documentation specifying the type can lead to claim denials and inaccurate data.
Incorrectly coding secondary diabetes with hyperglycemia due to underlying conditions (e.g., steroid-induced) can impact quality metrics and reimbursement.
Coding hyperglycemia based on single, unconfirmed high blood glucose readings without supporting documentation or follow-up can result in audits and inaccurate reporting.
Patient presents with hyperglycemia, elevated blood glucose levels, indicative of possible diabetes mellitus, impaired glucose tolerance, or other metabolic disorder. Presenting symptoms include polyuria, polydipsia, polyphagia, and fatigue. Onset of symptoms reported as gradual over the past several weeks. Fasting blood glucose level of [Insert Value] mgdL confirms hyperglycemia diagnosis. HbA1c level of [Insert Value]% measured. Patient denies any history of diabetes. Family history significant for type 2 diabetes mellitus in mother and paternal grandfather. Physical examination reveals no acute distress. Assessment includes review of systems, vital signs, and complete blood count. Differential diagnosis considers type 1 diabetes, type 2 diabetes, gestational diabetes if applicable, stress-induced hyperglycemia, and medication-induced hyperglycemia. Plan includes initiation of [Medication name and dosage], dietary counseling focusing on carbohydrate management and blood glucose monitoring, referral to a certified diabetes educator for patient education on diabetes management, and follow-up appointment scheduled in two weeks to reassess blood glucose control and adjust treatment plan as needed. Patient education provided on signs and symptoms of hypoglycemia and hyperglycemia, sick day management, and importance of medication adherence. ICD-10 code E11.9, R73.0.