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Austin Regional Clinic
ICD-10-CM Documentation Quick Reference Guide
Diabetes Mellitus
ICD-9
CODE
ICD-9 DESCRIPTION
ICD-10
CODE
More specific ICD-10 options
include:
Not a complete list
250.00
Diabetes mellitus (DM) without mention of complication,
type II or unspecified type, not stated as uncontrolled
ICD-10 DESCRIPTION
E10.9
Type 1 diabetes mellitus w/o
complications
E11.9
Type 2 diabetes mellitus w/o
complications
E13.9
Other specified diabetes mellitus
w/o complications
O24.419
Gestational diabetes mellitus in
pregnancy, unspec control
E10.621
Type 1 DM with foot ulcer
E10.52
Type 1 DM with peripheral
angiopathy with gangrene
E11.12
Type 2 DM with diabetic
nephropathy
E11.22
Type 2 DM with diabetic CKD
E11.610
Type 2 DM with diabetic
neuropathic arthropathy
(Charcot’s joint)
DOCUMENTATION
CONCEPTS
Type:
Type 1 (E10.9)
Type 2 (E11.9)
Secondary DM (with type 1 or 2)
 Underlying etiology (i.e. chemical
or drug-induced, autoimmune, etc.)
Associated complications:
Gestational diabetes
Diabetic foot ulcer
Diabetic nephropathy / diabetic CKD
Diabetic peripheral angiopathy
Diabetic autonomic neuropathy
Charcot’s joint(s)
Diabetic osteomyelitis (Relationship is
no longer presumed; Need to link the
two conditions, if appropriate)
 Acuity (acute, subacute, chronic)
 Location (ankle, foot, vertebra, etc.)
 Laterality (right, left, bilateral)
 Infectious agent
With gangrene
With hyperglycemia
Control status
(No longer “controlled or uncontrolled”)
Out of control
Poorly controlled
Insulin use:
Long-term (current) insulin (Z79.4)
Underdosing or overdosing related to
insulin pump malfunction
 Intentional, unintentional
 Reason (financial, dementia, etc.
Austin Regional Clinic
ICD-10-CM Documentation Quick Reference Guide
Diabetes Mellitus
ICD-9 DESCRIPTION
ICD-10 DESCRIPTION
INAPPROPRIATE DOCUMENTATION EXAMPLE
APPROPRIATE DOCUMENTATION EXAMPLE
Diagnosis: 250.00 Diabetes mellitus without mention of
complication, type II or unspecified type, not stated as
uncontrolled
HPI: Diabetes - eating sweets. Sugars 132 and 117. Taking medications
regularly. Exercising regularly.
Assessment/Plan:
Unspecified Diabetes Mellitus
Chronic kidney disease (CKD)
- continue current medications
Concept(s) requirement not met: no type indicated, control status not
documented, no relationship link to complications, no plan of care
Diagnosis: E11.22 Type 2 Diabetes Mellitus with diabetic CKD
HPI: This patient is seen today with numerous medical problems that include OSA on
CPAP, DM II, Obesity, Hypothyroidism, CKD due to DM and Hyperlipidemia who
presents highly spirited for re-evaluation. + FHX of DM. He was last seen 3 months
ago, at which point labs showed GFR 46, glucose 160, HgbA1c of 7.2.
Assessment/Plan:
Diabetes Mellitus, Type 2, poorly controlled
Diabetic nephropathy with CKD Stage III
- Metabolic, Comprehensive
- Hemoglobin A1C-HPLC; Future
- CBC W/Diff (auto); Future
- sitaGLIPtin (JANUVIA) 100 MG PO tablet; Take 1 tablet (100 mg total) by mouth daily
Concept(s) requirement not met: no type indicated, control status not documented,
no relationship link to complications, no plan of care