Find information on uncontrolled type 2 diabetes mellitus including diagnosis codes, clinical documentation improvement tips, and healthcare management guidelines. Learn about ICD-10-CM codes for uncontrolled diabetes, A1c levels in uncontrolled diabetes, diabetes complications, and best practices for documenting uncontrolled diabetes in medical records. Explore resources for healthcare professionals on managing and coding uncontrolled type 2 diabetes.
Also known as
Type 2 diabetes mellitus
Uncontrolled type 2 diabetes codes with various complications.
Uncontrolled type 2 diabetes
Specifically designates uncontrolled type 2 diabetes mellitus.
Long term (current) drug therapy
Indicates ongoing medication use, often relevant to diabetes management.
Diabetes mellitus
Encompasses all forms of diabetes mellitus for broader context.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the Type 2 Diabetes Mellitus uncontrolled?
No
Do not code as uncontrolled. Review documentation for other diagnoses.
Yes
Is there chronic kidney disease?
When to use each related code
| Description |
|---|
| Uncontrolled Type 2 Diabetes |
| Controlled Type 2 Diabetes |
| Prediabetes |
Missing documentation of A1C, hyperglycemia signs/symptoms, or chronic complications leading to inaccurate coding (E11.65 vs E11.9).
Lack of specific documentation for diabetic complications (retinopathy, nephropathy, neuropathy) causing undercoding and lost revenue.
Failure to accurately capture HCCs related to uncontrolled diabetes impacting risk adjustment and reimbursement.
Q: What are the most effective strategies for intensifying insulin therapy in patients with uncontrolled type 2 diabetes mellitus and persistent hyperglycemia despite oral medications?
A: Intensifying insulin therapy for uncontrolled type 2 diabetes mellitus requires a patient-centered approach. When persistent hyperglycemia occurs despite oral medications, clinicians should first assess patient adherence, lifestyle factors (diet, exercise), and comorbidities. Evidence-based strategies for intensification include: 1) Titrating basal insulin doses based on fasting blood glucose levels, using algorithms or individualized protocols. 2) Adding bolus insulin before meals, starting with the largest meal and adjusting based on postprandial glucose monitoring. 3) Switching to a premixed insulin analog for simplified administration. 4) Considering newer agents like GLP-1 receptor agonists or SGLT2 inhibitors in conjunction with insulin. Careful monitoring for hypoglycemia is crucial during insulin intensification. Explore how incorporating continuous glucose monitoring can facilitate titration and reduce hypoglycemic events. Consider implementing a shared decision-making process to tailor insulin regimens to individual patient needs and preferences.
Q: How can clinicians differentiate between insulin resistance and beta-cell dysfunction when managing uncontrolled type 2 diabetes mellitus and formulating a personalized treatment plan?
A: Differentiating insulin resistance from beta-cell dysfunction is key to personalized management of uncontrolled type 2 diabetes mellitus. Clinical indicators like elevated fasting C-peptide levels suggest insulin resistance predominates, while low C-peptide indicates significant beta-cell dysfunction. Homeostatic model assessment (HOMA-IR and HOMA-B) can provide quantitative assessments. Other markers like adiponectin and proinsulin levels can further clarify the pathophysiology. Understanding the dominant mechanism guides treatment choices: insulin sensitizers like metformin are primarily beneficial in insulin resistance, while insulin therapy is crucial when beta-cell function is significantly impaired. GLP-1 receptor agonists can address both insulin resistance and beta-cell dysfunction. Learn more about advanced testing options to assess beta-cell function in detail and tailor treatment accordingly.
Patient presents with uncontrolled type 2 diabetes mellitus. The patient reports persistent hyperglycemia despite current management. Symptoms include polyuria, polydipsia, and polyphagia. Review of systems reveals fatigue, blurred vision, and occasional paresthesia in the lower extremities. Medical history significant for long-standing type 2 diabetes, hypertension, and hyperlipidemia. Current medications include metformin, glipizide, and atorvastatin. Laboratory results demonstrate elevated HbA1c of 9.5%, fasting blood glucose of 220 mgdL, and elevated triglycerides. Physical examination reveals no acute distress, but findings consistent with peripheral neuropathy are noted. Assessment confirms uncontrolled diabetes mellitus type 2, poorly controlled blood sugar, diabetic neuropathy, and hypertriglyceridemia. Plan includes adjustment of current diabetic medication regimen, intensification of diabetes self-management education focusing on carbohydrate counting and blood glucose monitoring, referral to a registered dietitian for nutritional counseling, and consideration for adjunctive therapy. Emphasis on medication adherence, lifestyle modifications including regular exercise, and follow-up appointment scheduled in two weeks to reassess glycemic control and adjust treatment as needed. Diabetes management education materials provided and reviewed. Patient verbalized understanding of the plan and expressed willingness to actively participate in self-management strategies. Diagnosis codes include E11.9, uncontrolled type 2 diabetes mellitus without complications; E11.40, type 2 diabetes mellitus with diabetic neuropathy; and E78.2, hyperlipidemia.