E11.65
Type 2 diabetes mellitus with hyperglycemia
Type 2 diabetes mellitus with hyperglycemia is a clinical manifestation where a patient diagnosed with Type 2 DM presents with elevated blood glucose levels above the target range. This condition reflects inadequate glycemic control, often identified during acute presentations or routine monitoring where fasting or random glucose levels exceed standard thresholds (e.g., fasting glucose >125 mg/dL). It is a specific sub-classification used to denote that the patient's diabetes is currently in a hyperglycemic state, which may necessitate adjustments to pharmacological therapy or lifestyle interventions. While 'uncontrolled' was used in ICD-9, ICD-10-CM utilizes specific descriptors like 'with hyperglycemia' to provide better clinical clarity.
Clinical Symptoms
- Increased thirst (polydipsia)
- Frequent urination (polyuria)
- Increased hunger (polyphagia)
- Blurred vision
- Fatigue and lethargy
- Slow-healing sores
- Frequent infections
- Headache
Common Causes
- Insulin resistance in peripheral tissues
- Progressive beta-cell exhaustion and dysfunction
- Dietary indiscretion and high carbohydrate intake
- Physical inactivity
- Acute physiological stress or illness
- Medication non-adherence
- Hormonal imbalances
- Side effects from medications such as corticosteroids
Documentation & Coding Tips
Explicitly link hyperglycemia to the type of diabetes in the diagnostic statement.
Example: Documenting 'Type 2 Diabetes with hyperglycemia' instead of 'High blood sugar in a patient with DM.'
Specify the type of diabetes as Type 2 (E11.-) to avoid the default code which might not reflect the patient's true condition.
Example: Document 'Type 2 Diabetes Mellitus' clearly in the assessment and plan.
If the patient's hyperglycemia is due to an underlying condition or medication, document that relationship clearly.
Example: 'Type 2 DM with hyperglycemia due to acute bronchitis and steroid use.'