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E11.9
ICD-10-CM
Type 2 Diabetes Without Complications

Find information on Type 2 diabetes without complications, including ICD-10 code E11.9, diagnosis criteria, clinical documentation tips, and healthcare provider resources. Learn about managing uncomplicated diabetes, blood glucose monitoring, and lifestyle modifications. Explore relevant medical coding guidelines and best practices for accurate reporting of Type 2 diabetes without complications in medical records.

Also known as

Type 2 Diabetes Mellitus Without Complications
Non-Insulin Dependent Diabetes Without Complications
t2dm without complications

Diagnosis Snapshot

Key Facts
  • Definition : Chronic metabolic disorder marked by high blood sugar due to insulin resistance and relative insulin deficiency.
  • Clinical Signs : Frequent urination, excessive thirst, unexplained weight loss, increased hunger, blurred vision, fatigue.
  • Common Settings : Primary care, endocrinology, diabetes education programs, telehealth.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC E11.9 Coding
E11

Type 2 diabetes mellitus

Covers type 2 diabetes without complications.

E11.9

Type 2 diabetes mellitus without complications

Specifies type 2 diabetes with no documented complications.

Z79.4

Long term current drug therapy

May be used if patient is on medication for diabetes.

E08-E13

Diabetes mellitus

Encompasses all forms of diabetes mellitus.

Code-Specific Guidance

Decision Tree for

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

Is the diabetes Type 2?

  • Yes

    Any documented complications?

  • No

    Is it Type 1?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Type 2 diabetes without complications
Prediabetes
Gestational diabetes

Documentation Best Practices

Documentation Checklist
  • Type 2 diabetes without complications diagnosis documented
  • HbA1c level or fasting glucose results included
  • Symptoms or signs of diabetes documented if present
  • Absence of complications explicitly stated
  • ICD-10 code E11.9 documented

Coding and Audit Risks

Common Risks
  • Unspecified DM2 Code

    Using unspecified codes (E11.9) when documentation supports a more specific type 2 diabetes code with no complications (E11.65).

  • Comorbidity Overlap

    Incorrectly coding conditions like prediabetes or gestational diabetes as type 2 diabetes without complications.

  • Missing Documentation

    Lack of clear documentation supporting the diagnosis of type 2 diabetes without complications, leading to coding errors and potential denials.

Mitigation Tips

Best Practices
  • Code Z09.0 for enc w/o complication, ICD-10-CM guidelines
  • Document diet, exercise, meds, A1c for accurate E/M coding
  • Regular chart reviews for CDI of T2DM w/o complications
  • Follow HEDIS measures for diabetes care, ensure compliance
  • Timely screenings, education for HCC coding, risk adjustment

Clinical Decision Support

Checklist
  • 1. HbA1c >= 6.5% documented?
  • 2. Fasting glucose >= 126 mg/dL?
  • 3. Random glucose >= 200 mg/dL + symptoms?
  • 4. Exclude type 1 diabetes, other causes.

Reimbursement and Quality Metrics

Impact Summary
  • Type 2 Diabetes Without Complications reimbursement hinges on accurate ICD-10-CM coding (E11.-) and proper documentation for optimal payer payments.
  • Quality metrics impacted: HbA1c control, blood pressure management, eye exam completion. Accurate coding affects hospital quality reporting and value-based payments.
  • Coding errors for E11.- can lead to claim denials, impacting revenue cycle and reimbursements. Specificity in documentation is crucial.
  • Diabetes without complications coding linked to HEDIS measures directly influencing hospital performance scores and potential penalties.

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 E11.9, Type 2 diabetes mellitus without complications
  • Confirm diagnosis documentation
  • Exclude secondary diabetes codes
  • Avoid unspecified codes if documented
  • Review OGCR for coding guidelines

Documentation Templates

Patient presents with a diagnosis of Type 2 Diabetes Mellitus without complications.  The patient's current presentation aligns with established diagnostic criteria for Type 2 diabetes, including elevated HbA1c levels (most recent result [insert value] recorded on [date]) and consistent hyperglycemia.  Symptoms reported include polyuria, polydipsia, and occasional blurred vision.  No evidence of diabetic complications such as neuropathy, nephropathy, retinopathy, or cardiovascular disease was observed during this encounter.  Patient denies any history of diabetic ketoacidosis.  Family history is positive for Type 2 diabetes.  Current medications include [list current medications].  Dietary counseling regarding carbohydrate management and portion control was provided.  The patient was encouraged to increase physical activity levels with a goal of at least 150 minutes of moderate-intensity aerobic exercise per week.  Emphasis was placed on blood glucose monitoring and medication adherence.  The patient demonstrates understanding of self-management strategies and verbalizes commitment to lifestyle modifications.  Follow-up appointment scheduled in three months for HbA1c recheck and assessment of diabetes management progress.  Plan includes ongoing diabetes education and medication management as indicated by future lab results and clinical presentation.  ICD-10 code E11.9, Type 2 diabetes mellitus without complications, is assigned.
Type 2 Diabetes Without Complications - AI-Powered ICD-10 Documentation