Documentation and Coding Guidance - Diabetes Mellitus

Feb. 01, 2021

High quality documentation and complete, accurate coding can help capture our members' health status and promote continuity of care. Below are resources for documenting and coding diabetes mellitus (DM). This information is from the ICD-10-CM Official Guidelines for Coding and Reporting  and the sources listed below*.

Codes for DM Types
DM types are divided into five categories:

• E08 DM due to underlying condition
• E09 Drug or chemical induced DM
• E10 Type 1 DM
• E11 Type 2 DM
• E13 Other specified DM

ICD-10-CM requires documentation to specify DM with hyper- or hypoglycemia, instead of controlled or uncontrolled. Without this documentation, DM unspecified will be coded.

Specificity Matters
These categories are further divided into subcategories of four, five or six characters. They include the DM type, the body system affected and the complications affecting that body system.

Best Practices

• Include patient demographics, such as name and date of birth, and date of service in all progress notes.
• Document legibly, clearly and concisely.
• Ensure documents are signed and dated by a credentialed provider.
• Document each diagnosis as having been monitored, evaluated, assessed and/or treated on the date of service.
• Note complications with an appropriate treatment plan.
• Assign as many codes as needed to describe all disease complications. This includes combination codes (such as E11.621 Type 2 DM with foot ulcer) and additional codes (such as CKD stage and ulcer site).
• Assign codes appropriate for the patient's condition.
• Take advantage of the Annual Health Assessment (AHA) or other yearly preventative exam to capture all conditions impacting member care.

*For more details, see:

• 2020 ICD-10-CM Official Guidelines for Coding and Reporting , Chapter 4: Endocrine, Nutritional and Metabolic Diseases (E08-E13)
• Centers for Medicare & Medicaid Services Risk Adjustment Data Validation (RADV) Medical Record Checklist and Guidance 
• BCBSMT Medicare Advantage Annual Wellness Visit Guide

Questions? Contact BCBSMT Network Management .

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The material presented here is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients' conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly.