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E16.2
ICD-10-CM
Hypoglycemia

Find information on hypoglycemia diagnosis, including clinical documentation tips, ICD-10 codes (E16.2), SNOMED CT concepts, and healthcare provider resources. Learn about low blood sugar symptoms, treatment, and management for accurate medical coding and improved patient care. This resource covers relevant medical terminology, clinical guidelines, and best practices for documenting hypoglycemia in electronic health records. Explore details on diagnostic criteria and coding for hypoglycemia unawareness and other related conditions.

Also known as

Low blood sugar
Hypoglycemic episode

Diagnosis Snapshot

Key Facts
  • Definition : Low blood glucose (typically <70 mg/dL)
  • Clinical Signs : Shakiness, sweating, confusion, dizziness, hunger
  • Common Settings : Diabetes treatment, fasting, certain medications

Related ICD-10 Code Ranges

Complete code families applicable to AAPC E16.2 Coding
E15-E16

Nondiabetic hypoglycemic coma

Hypoglycemia without diabetes.

E10-E14

Diabetes mellitus

Diabetes may be associated with hypoglycemia.

R73

Abnormal glucose

Includes abnormal blood sugar levels like hypoglycemia.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is hypoglycemia drug-induced?

  • Yes

    Due to insulin?

  • No

    Due to other external cause?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Low blood sugar
Insulin reaction
Postprandial hypoglycemia

Documentation Best Practices

Documentation Checklist
  • Hypoglycemia diagnosis: document Whipple's triad
  • Confirm low blood glucose level <70 mg/dL
  • Document symptoms: shakiness, sweating, etc.
  • Note correlating circumstances: fasting, insulin
  • Specify hypoglycemia type: drug-induced, reactive

Coding and Audit Risks

Common Risks
  • Unspecified Hypoglycemia

    Coding E16.2 without documentation specifying drug-induced, fasting, or other types leads to inaccurate severity and impacts reimbursement.

  • Neonatal Hypoglycemia

    Miscoding transient neonatal hypoglycemia (P70.2) as E16.2 can result in inflated case mix index and incorrect quality metrics.

  • Symptom vs. Diagnosis

    Coding symptoms like dizziness (R42) without a confirmed hypoglycemia diagnosis (E16.2) can underestimate patient acuity and affect quality reporting.

Mitigation Tips

Best Practices
  • Document Whipple's triad for accurate ICD-10 coding (E16.2).
  • Ensure detailed glucose levels, symptoms, and response to treatment in clinical documentation for improved CDI.
  • Regular staff training on hypoglycemia diagnosis and management for healthcare compliance.
  • Standardized protocols for point-of-care glucose testing and hypoglycemia treatment.
  • Use validated questionnaires for hypoglycemia symptom assessment and accurate coding.

Clinical Decision Support

Checklist
  • Confirm Whipple's triad: symptoms, low glucose, relief with glucose.
  • Document BG <70 mg/dL (3.9 mmol/L) - ICD-10 E16.2
  • Review medications: insulin, sulfonylureas - RxNorm
  • Assess for contributing factors: fasting, exercise
  • Consider other diagnoses if Whipple's triad incomplete - Patient Safety

Reimbursement and Quality Metrics

Impact Summary
  • Hypoglycemia reimbursement hinges on accurate coding (E16.x) and documentation of severity, impacting MS-DRG assignment and payment.
  • Coding errors for Hypoglycemia (e.g., unspecified vs. documented cause) lead to claim denials, reduced revenue, and lower case mix index.
  • Quality metrics like timely glucose monitoring and treatment are crucial for Hypoglycemia, impacting hospital performance scores and value-based payments.
  • Accurate Hypoglycemia documentation supports severity-based coding, improving data accuracy for hospital reporting and clinical quality improvement.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code E16.2 for non-diabetic hypoglycemia
  • Document Whipple's triad if applicable
  • Query physician if cause unclear
  • Consider E15 if due to insulin
  • E10-E14 if due to diabetes

Documentation Templates

Patient presents with signs and symptoms consistent with hypoglycemia.  Presenting complaints include sweating, tremor, weakness, dizziness, lightheadedness, confusion, and palpitations.  Onset of symptoms occurred approximately [time] and was associated with [precipitating factors, e.g., missed meal, excessive exercise, insulin overdose].  Patient reports a history of [diabetes type 1, diabetes type 2, gestational diabetes, other] and is currently managed on [medication regimen, e.g., insulin therapy, oral hypoglycemic agents, dietary management].  Blood glucose level measured via [fingerstick, venous draw] was [numerical value] mgdL.  Patient was treated with [treatment provided, e.g., 15g of fast-acting carbohydrate, IV dextrose] resulting in symptomatic improvement.  Repeat blood glucose after treatment was [numerical value] mgdL.  Patient education provided regarding hypoglycemia prevention, including consistent meal timing, appropriate carbohydrate intake, and medication management.  Diagnosis of hypoglycemia confirmed based on clinical presentation, low blood glucose level, and response to treatment.  ICD-10 code E16.2 (Hypoglycemia, unspecified) assigned.  Follow-up with [healthcare provider, e.g., primary care physician, endocrinologist] recommended for ongoing diabetes management and hypoglycemia prevention strategies.