E11.65

🩺 ICD-10 E11.65: Type 2 Diabetes Mellitus with Hyperglycemia

Quick Reference Table

Element	Value
ICD-10 Code	E11.65
Diagnosis	Type 2 diabetes mellitus with hyperglycemia
Parent Category	E11 - Type 2 diabetes mellitus
Chapter	IV - Endocrine, nutritional and metabolic diseases (E00 -E89)
Billable	✓ Yes
Requires 7th Digit	✗ No (fully specified)
HCC Status	YES - HCC 18 (risk weight 0.368)
Related Terminology	Uncontrolled diabetes, poorly controlled diabetes, out of control diabetes, inadequately controlled diabetes
Most Common Cause	Insulin resistance + inadequate medication management or lifestyle non-adherence
Average A1C Range	>7.0% to >10%+ (varies by patient)
Typical Age of Onset	45 -65 years; increasingly younger (30s -40s)
Comorbidities	Hypertension, dyslipidemia, obesity, diabetic nephropathy, neuropathy, retinopathy, cardiovascular disease

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Short Definition

E11.65 is an ICD-10-CM diagnosis code that specifies Type 2 diabetes mellitus accompanied by hyperglycemia - a condition characterized by persistently elevated blood glucose levels above the therapeutic/target range. Hyperglycemia in Type 2 diabetes reflects inadequate glycemic control due to insufficient insulin production and/or insulin resistance, and is coded when documentation includes terms such as “uncontrolled,” “poorly controlled,” “inadequately controlled,” “out of control,” or when provider explicitly documents hyperglycemia[1]. The code carries HCC 18 weight (0.368) in risk-adjustment payment models, indicating moderate risk elevation for the Medicare Advantage population[2].

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Full Description

Pathophysiology of Hyperglycemia in Type 2 Diabetes

Type 2 diabetes mellitus is characterized by:

• Insulin resistance: Peripheral tissues (skeletal muscle, adipose tissue, liver) fail to respond adequately to insulin signaling
• β-cell dysfunction: Progressive loss of insulin-secreting pancreatic beta-cell function over time
• Net result: Circulating glucose remains elevated because it cannot be effectively transported into cells or utilized for energy[1][3]

Hyperglycemia develops when:

• Blood glucose exceeds the renal threshold (~180 mg/dL plasma glucose), or
• Fasting glucose consistently >126 mg/dL (7.0 mmol/L), or
• Hemoglobin A1C (HbA1c) >7.0% (or provider-defined target, typically 6.5 -8.0% depending on age/comorbidities)[1]

Mechanisms causing uncontrolled hyperglycemia in Type 2 DM:[1][3]

• Medication non-adherence or inadequate dosing
• Dietary non-compliance (excessive carbohydrate intake, poor meal timing)
• Physical inactivity or sedentary lifestyle
• Acute stress or infection (counter-regulatory hormones elevate glucose)
• Newly diagnosed diabetes without yet-optimized treatment
• Progression of beta-cell failure requiring medication adjustment or insulin initiation
• Comorbidities worsening insulin resistance (obesity, polycystic ovary syndrome, hypothyroidism)

Clinical Presentation

Acute or subacute symptoms of hyperglycemia:[1][3]

• polyuria (frequent urination, often nocturia 2 -3 times per night)
• Polydipsia (excessive thirst)
• Polyphagia (excessive hunger despite eating)
• Weight loss (paradoxically, despite eating more; due to urinary glucose loss)
• Fatigue, weakness, lethargy
• Blurred vision (osmotic lens swelling from hyperglycemia)
• Headaches, difficulty concentrating
• Slow-healing wounds or recurrent infections (impaired neutrophil function, hyperglycemia-induced immunosuppression)[1]

Chronic complications from sustained hyperglycemia:[1][3]

• Microvascular: Retinopathy (vision loss/blindness), nephropathy (kidney disease), neuropathy (nerve damage, foot ulcers)
• Macrovascular: Coronary artery disease, stroke, peripheral arterial disease
• Other: Erectile dysfunction, gastroparesis, hearing loss, skin infections

Laboratory findings supporting E11.65:[1][2]

• Fasting blood glucose: >126 mg/dL (7.0 mmol/L)
• Random blood glucose: >200 mg/dL (11.1 mmol/L) with symptoms
• Hemoglobin A1C: >7.0% (some targets 6.5 -8.0% based on age/comorbidities)
• Oral glucose tolerance test (OGTT): 2-hour value >200 mg/dL after 75 g glucose load

Diagnostic Criteria (Per ADA & CMS)

Diagnosis of Type 2 diabetes:[1][3]

1. Fasting plasma glucose ≥126 mg/dL (7.0 mmol/L), OR
2. 2-hour post-load plasma glucose ≥200 mg/dL during 75 g OGTT, OR
3. Random plasma glucose ≥200 mg/dL with hyperglycemic symptoms, OR
4. HbA1c ≥6.5%

Hyperglycemia component (for E11.65 specificity):[2]

• Provider documents diabetes is “uncontrolled,” “poorly controlled,” “inadequately controlled,” or “out of control”
• OR provider explicitly documents hyperglycemia or elevated glucose levels
• ICD-10 guidelines: CMS presumes cause-and-effect relationship between diabetes and hyperglycemia; explicit linkage NOT required in documentation[2]

Differentiation from Other Diabetes Codes

Code	Description	Use When
E11.9	Type 2 diabetes without complications	Stable, controlled diabetes; no hyperglycemia/hypoglycemia documented
E11.65	Type 2 diabetes with hyperglycemia	Uncontrolled/poorly controlled; elevated glucose levels (THIS CODE)
E11.649	Type 2 diabetes with hypoglycemia without coma	Recurrent low blood sugar episodes (opposite of hyperglycemia)
E11.641	Type 2 diabetes with hypoglycemia with coma	Severe hypoglycemia causing loss of consciousness
E10.65	Type 1 diabetes with hyperglycemia	Type 1 diabetes (autoimmune), not Type 2 (use E11 instead)
E13.65	Other specified diabetes with hyperglycemia	Gestational, drug-induced, or secondary diabetes
E11.21	Type 2 diabetes with diabetic nephropathy	Kidney complication (may coexist with E11.65)
E11.22	Type 2 diabetes with diabetic CKD	Chronic kidney disease complication (may coexist)
E11.31 -E11.39	Type 2 diabetes with retinopathy	Eye complication (may coexist with E11.65)
E11.40 -E11.49	Type 2 diabetes with neuropathy	Nerve complication (may coexist with E11.65)

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HCC (Hierarchical Condition Category) Status

E11.65 HCC Status: YES - HCC Category 18

HCC Category 18 Details:[2][4]

• Risk Weight (2026): 0.368
• Relative Risk: Approximately 37% higher than baseline risk
• Type: Chronic condition indicating diabetes with suboptimal control
• CMS Role: Used in Medicare Advantage risk-adjustment models to calculate capitation payments and quality metrics
• Hierarchies: HCC 18 is non-hierarchical to most other diabetes codes; however, if patient has multiple diabetes complication codes (e.g., E11.22 CKD + E11.65 hyperglycemia), both should be coded per clinical documentation[2][4]

Why E11.65 is HCC-weighted:[4]

• Hyperglycemia indicates suboptimal disease management and elevated risk for acute and chronic complications
• Drives higher healthcare costs (hospitalization for DKA/HHS, complications management, increased medication utilization)
• Signals need for intervention (medication adjustment, intensive counseling, specialist referral)

HCC Coding Implications:[2][4]

• For MA Plans: Document hyperglycemia explicitly to capture HCC 18 and optimize RAF (Risk Adjustment Factor) score
• For Traditional Medicare: E11.65 does NOT carry HCC weight, but still important for clinical documentation and quality metrics
• For ACOs/Value-Based Contracts: Proper coding of E11.65 reflects actual patient complexity and justifies higher resource utilization

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Coding Specifics

Code Structure Breakdown

Component	Value	Meaning
1st -3rd characters	E11	Type 2 diabetes mellitus (parent category)
4th character	.6	Type 2 diabetes with other specified complications
5th character	5	Hyperglycemia (elevated blood glucose)

Note

Full code: E11.65 is fully specified and billable as written. No additional digit required.

When to Code E11.65

✓ Use E11.65 when:

• Patient has confirmed Type 2 diabetes diagnosis
• Provider documentation includes “uncontrolled,” “poorly controlled,” “inadequately controlled,” “out of control,” or “hyperglycemia”
• Glucose levels are documented as elevated (fasting >126, random >200, A1C >7%)
• Patient is admitted/seen for management of diabetes with suboptimal control
• ICD-10 guidelines presume cause-and-effect; no explicit linkage required[2]

✗ Do NOT use E11.65 when:

• Diabetes is stable and well-controlled (use E11.9 instead)
• Type 1 diabetes (use E10.65)
• Other types of diabetes (gestational, secondary, drug-induced → use E13.65)
• Only hypoglycemia is documented without hyperglycemia (use E11.649)
• No documented complication or control status (default to E11.9)

Z-Codes to Report Concurrently with E11.65

Always include appropriate Z-codes for medication use:[2]

Code	Description	Use When
Z79.4	Long-term (current) use of insulin	Patient on insulin therapy
Z79.84	Long-term (current) use of oral antidiabetic drugs	Patient on metformin, sulfonylureas, DPP-4 inhibitors, SGLT2i, GLP-1 RA, etc.
Z79.85	Long-term (current) use of injectable non-insulin antidiabetic drugs	Patient on GLP-1 agonists (semaglutide, tirzepatide), other injectables
Z71.3	Dietary counseling	If counseling provided during encounter
Z71.82	Exercise counseling	If exercise/lifestyle modification counseled
Z79.5	Long-term (current) use of steroids (systemic)	If on corticosteroids contributing to hyperglycemia

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Documentation Requirements (For Accurate Coding)

Critical Elements to Document

Provider documentation MUST include:[2][3]

1. Explicit diagnosis of Type 2 diabetes: “Type 2 diabetes mellitus,” “T2DM,” or “NIDDM” (not just “diabetes” without type)
2. Glycemic control status: “Uncontrolled,” “poorly controlled,” “inadequately controlled,” “out of control,” or “hyperglycemia”
   • Insufficient: “Diabetes” alone, “treated with insulin,” or “medication adjustment needed”
   • Sufficient: “Type 2 diabetes, uncontrolled, A1C 9.2%”
3. Glucose/A1C values (when available):
   • Fasting glucose, random glucose, or A1C percentage
   • Dates of measurement to trend over time
4. Current medications: List of antidiabetic drugs, insulin type/dose, frequency
5. Medication adherence assessment: Is patient compliant? Barriers to adherence? Cost, side effects, polypharmacy burden?
6. Lifestyle factors:
   • Diet adherence: Following diabetic diet? Carbohydrate counting?
   • Exercise: Sedentary vs active; any barriers?
   • Monitoring: Self-blood glucose monitoring (SBGM)? Continuous glucose monitor (CGM)?
7. Associated complications (if present): Retinopathy, nephropathy, neuropathy, cardiovascular disease, etc.
8. Comorbidities: Hypertension, obesity, dyslipidemia, sleep apnea, thyroid disease
9. Reason for encounter: Routine follow-up, acute decompensation, medication adjustment, complication assessment?

Provider Documentation Red Flags

⚠️ Insufficient/ambiguous documentation:

• “Patient has diabetes” → Does not specify Type 2 or control status; coder defaults to E11.9 (without complications)
• “Patient stable on metformin” → May suggest controlled; insufficient to justify E11.65 without explicit uncontrolled statement
• “DM, A1C 8.5%” → Without provider assessment of control, coder may not code E11.65 (though A1C >7% supports it per guidelines)
• “Uncontrolled” alone → Ambiguous; could mean hypo- or hyperglycemia; requires clarification

Note

Best practice: Use phrase “poorly controlled” or “inadequately controlled” with documented glucose/A1C to eliminate ambiguity[2].

Audit Checklist

When E11.65 is billed, auditors review:

• Type 2 diabetes confirmed in chart? (vs Type 1)
• “Uncontrolled,” “poorly controlled,” or hyperglycemia documented?
• Glucose or A1C values present to support inadequate control?
• Current medications listed?
• Medication adherence addressed in note?
• If multiple complications coded, are all documented?

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Associated CPT Codes (Procedures/Services Commonly Billed with E11.65)

Evaluation & Management (E/M) Services

CPT	Description	Typical Use
99201 -99205	Office visit - new patient (Levels 1 -5)	Initial diabetes assessment in office
99211 -99215	Office visit - established patient (Levels 1 -5)	Routine or urgent diabetes follow-up
99281 -99285	Emergency department visit (Levels 1 -5)	DKA, HHS, hypoglycemia, or acute hyperglycemic crisis
99221 -99223	Inpatient hospital visit - initial (Levels 1 -3)	Hospital admission for uncontrolled diabetes/complications
99231 -99233	Inpatient hospital visit - subsequent (Levels 1 -3)	Daily management during hospitalization

Note

Typical E/M level 3 -4 used for diabetes management given moderate to high complexity.

Diagnostic Services & Labs

CPT	Description
83036	Hemoglobin A1C (glycated hemoglobin) - most critical for diabetes monitoring
82947	Glucose, fasting
82962	Glucose, 2-hour post-glucose load (oral glucose tolerance test)
85025	Complete blood count (CBC) with differential; assess for infection/complications
80053	Comprehensive metabolic panel (CMP); assess kidney/liver function, electrolytes
84702	Chorionic gonadotropin, qualitative (β-hCG) - if reproductive-age female to rule out gestational diabetes

Continuous Glucose Monitoring (CGM)

CPT	Description
95250	Continuous glucose monitoring data download and review (monthly)
K1000 -K1004	CGM device application/insertion (varies by device)

Medication Administration

CPT	Description
96372	Therapeutic injection; single or initial injection
96365 -96368	Intravenous infusion (insulin infusion in hospital setting)

Preventive Care & Education

CPT	Description
99211 or time-based	Diabetes self-management education (DSME) - covered if E11.65 present
99212 -99214	Medical nutrition therapy (MNT) encounter (if separate visit)

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Treatment & Clinical Management

Pharmacologic Management (Evidence-Based Approach)

First-line antidiabetic agents for Type 2 DM with hyperglycemia:[1][3]

Metformin (biguanide):

• Mechanism: Reduces hepatic glucose production, improves insulin sensitivity
• Dose: Start 500 mg daily -BID; titrate to max 2000 -2550 mg/day in divided doses
• A1C reduction: 1.5 -2%
• Advantages: Low hypoglycemia risk, weight neutral, cardioprotective, inexpensive
• Cautions: GI upset, vitamin B12 deficiency risk, contraindicated in severe renal disease (eGFR <30)
• Medication code (Z79.84): Assign if on oral antidiabetic drugs

Sulfonylureas (e.g., glyburide, glipizide):

• Mechanism: Stimulate pancreatic beta-cell insulin secretion
• A1C reduction: 1.5 -2%
• Risk: Hypoglycemia, weight gain
• Use: Typically second-line in modern practice due to hypoglycemia risk

Newer agents (increasingly first-line alternatives to/with metformin):[1]

GLP-1 Receptor Agonists (e.g., semaglutide, tirzepatide):

• A1C reduction: 1 -2.5%
• Advantages: Weight loss (2 -5 kg+), cardiovascular benefit, low hypoglycemia risk
• Medication code: Z79.85 (injectable non-insulin antidiabetic)

SGLT2 Inhibitors (e.g., empagliflozin, dapagliflozin):

• A1C reduction: 1 -1.5%
• Advantages: Weight loss, blood pressure reduction, cardioprotective, kidney-protective
• Medication code: Z79.84 (oral)

Insulin Therapy (for advanced/uncontrolled diabetes):

• Basal insulin: Longacting insulin (glargine, degludec) once daily
• Bolus/prandial insulin: Rapid-acting (aspart, lispro, glulisine) with meals
• Combination: Basal-bolus regimen for optimal control in poorly controlled Type 2 DM
• A1C reduction: 2 -3% (more potent than oral agents alone)
• Medication code: Z79.4 (long-term use of insulin)

Additional agents (DPP-4 inhibitors, thiazolidinediones, meglitinides):

• Used as second- or third-line agents based on comorbidities and side effect profile

Nonpharmacologic Management:[1][3]

• Diet: Carbohydrate counting, Mediterranean or DASH diet; aim for caloric deficit if overweight
• Exercise: 150 minutes moderate aerobic activity weekly + resistance training 2 -3×/week
• Weight loss: 5 -7% reduction improves insulin sensitivity significantly
• Self-monitoring: Home blood glucose monitoring (SBGM) or continuous glucose monitoring (CGM)
• Psychosocial support: Counseling for depression, anxiety, diabetes burnout (common in uncontrolled DM)

Monitoring & Follow-Up Intervals

• A1C: Every 3 -6 months (more frequent if recent medication change)
• Glucose logs/CGM data: Review at each visit if available
• Fasting blood glucose: At home or at clinic visits
• Comprehensive metabolic panel: Annually (kidney function, electrolytes)
• Lipid panel: Annually
• Urinalysis/urine albuminuria: Annually (screen for nephropathy)
• Retinal exam: Annually (dilated eye exam) or as needed for retinopathy screening
• Foot exam: At every visit (assess for neuropathy, ulcers)
• Blood pressure: At each visit

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Sample Documentation (Work-Ready Notes)

Scenario 1: Primary Care Office Visit (Established Patient)

Chief Complaint: Diabetes follow-up; patient reports “not feeling well”

HPI: 62-year-old female with Type 2 DM × 12 years on metformin 1000 mg BID and glipizide 5 mg BID. Patient admits poor dietary adherence over past 2 months (frequent fast food, increased sweet drinks). Works long hours, minimal exercise. Home glucose log shows readings 180 -240 mg/dL in mornings and 200 -280 mg/dL post-meal. No episodes of hypoglycemia. Reports increased polyuria (nocturia ×4 -5), polydipsia, and fatigue. Today’s fasting glucose: 218 mg/dL.

Physical Examination:

• Vitals: T 98.6°F, BP 148/92, HR 84, RR 16, Wt 205 lbs (BMI 31.8, up 5 lbs)
• General: Alert, oriented; mild fatigue noted
• Skin: No ulcers, good perfusion; feet warm, pulses intact
• Labs (today): Fasting glucose 218 mg/dL; A1C (from 3 weeks ago) 8.9% (previous A1C 6 months ago: 7.4%)

Assessment:

• Primary: Type 2 diabetes mellitus, poorly controlled/uncontrolled, with hyperglycemia
• Contributing factors: Poor medication adherence to diet, minimal exercise, weight gain, increased stress at work
• Current status: Rising A1C trend (7.4% → 8.9% over 6 months) concerning for worsening glycemic control

Plan:

• Medication adjustment: Increase glipizide to 10 mg BID (morning and evening before meals); consider adding GLP-1 agonist (semaglutide) if no improvement in 6 weeks
• Repeat labs: A1C in 3 months; recheck fasting glucose in 2 weeks
• Counseling: Diabetes self-management education (DSME) referral; dietary counseling focusing on carbohydrate awareness; exercise prescription (walking 30 min daily)
• Follow-up: Phone call in 1 week to assess tolerability of new glipizide dose; office visit in 6 weeks
• Preventive: Annual diabetic eye exam (order), annual foot exam (performed today; intact), kidney function monitoring (annual CMP ordered)

ICD-10 Codes:

• E11.65 (Type 2 diabetes with hyperglycemia)
• I10 (Essential hypertension, if documented)
• E78.5 (Dyslipidemia, if documented)
• Z79.84 (Long-term use of oral antidiabetic drugs)

CPT Codes:

• 99214 (Office visit, established patient, Level 4 MDM/time)
• 83036 (Hemoglobin A1C)
• 82947 (Glucose, fasting)

Scenario 2: Emergency Department Presentation (Acute Hyperglycemic Episode)

Chief Complaint: Severe headache, confusion, difficulty breathing × 4 hours

HPI: 58-year-old male with Type 2 DM diagnosed 5 years ago, not on any diabetes medications (did not fill prescriptions, states cost-prohibitive). Has not seen PCP in 2 years. Presented to ED with acute onset severe frontal headache, nausea, vomiting, generalized malaise, and shortness of breath. Wife reports patient has been increasingly confused over past 4 hours. No recent illness, trauma, or medication changes noted. Denies chest pain or focal neuro symptoms.

Physical Examination:

• Vitals: T 99.2°F, BP 176/104, HR 118, RR 28, O2 sat 93% on RA
• General: Alert but confused (oriented to person/place, confused about date); in acute distress
• HEENT: Dry mucous membranes; breath has fruity/acetone odor
• Lungs: Tachypneic, clear to auscultation
• Abdomen: Mild tenderness, no rebound

Labs (ED):

• Glucose: 547 mg/dL
• Arterial blood gas: pH 7.21 (acidotic), HCO3 12, pCO2 24 (respiratory compensation for metabolic acidosis)
• Beta-hydroxybutyrate: 4.2 mmol/L (positive, indicates ketoacidosis)
• Electrolytes: Na 126 (low, pseudohyponatremia from hyperglycemia), K 5.8 (high), Cl 98
• BUN/Cr: 48/2.1 (elevated, dehydration)
• Venous glucose: 549 mg/dL
• A1C: 13.5% (severely uncontrolled)

Assessment:

• Primary: Type 2 diabetes mellitus, severely uncontrolled with hyperglycemia
• Acute complication: Diabetic ketoacidosis (DKA) - blood glucose >400, pH <7.30, positive ketones, altered mental status
• Contributing factors: No diabetes medications (“non-compliant”), no recent preventive care (2 years since last visit)

Plan:

• Immediate actions: ICU admission; IV fluid resuscitation (normal saline bolus); insulin drip protocol (10 units/hour initial, titrate per glucose/labs); electrolyte monitoring (K+, Mg, phos); continuous cardiac monitoring
• Labs: Repeat glucose, electrolytes, arterial blood gas q1 hour until stable; then q2 -4 hours
• Medications: IV insulin drip; transition to subcutaneous insulin once acidosis resolved and oral intake tolerated
• Social: Case management for medication cost assistance; education on importance of adherence
• Follow-up: Endocrinology consult; diabetes education prior to discharge

ICD-10 Codes:

• E11.65 (Type 2 diabetes with hyperglycemia)
• E11.10 (Type 2 diabetes with ketoacidosis without coma - if DKA documented as separate code)
• I10 (Essential hypertension, if documented)
• R40.2 (Altered mental status, if coded separately)
• Z79.4 (Long-term use of insulin - after insulin initiated in ED/ICU)

CPT Codes:

• 99285 (ED visit, Level 5)
• 83036 (A1C)
• 82947 (Glucose)
• 80053 (Comprehensive metabolic panel)
• 82378 (Beta-hydroxybutyrate or ketones)

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Common Billing & Compliance Issues

Red Flags for Auditors

⚠️ Documentation gaps (high-risk for denial/query):

• “Type 2 diabetes” without control status → Auditor cannot confirm hyperglycemia component; coder queries back to provider or defaults to E11.9
• “Uncontrolled” without further specificity → Ambiguous; could mean hypo- or hyperglycemia; provider must clarify or say “poorly controlled” + glucose/A1C
• A1C >7% but no provider assessment → Auditor may accept per CMS guidelines presuming cause-and-effect, but explicit provider documentation is safer
• Multiple diabetes complications coded but not all documented → E.g., E11.65 + E11.21 (nephropathy) + E11.31 (retinopathy); auditor verifies each is documented separately
• Z79.4 (insulin) missing despite insulin use → Not a denial, but incomplete risk documentation; lowers RAF score
• E11.65 billed for controlled diabetes → Contradicts clinical picture if A1C <7% and patient reports good adherence; may trigger audit

⚠️ Coding errors:

• Confusing E11.65 (hyperglycemia) with E11.649 (hypoglycemia) → Opposite conditions; different treatment implications and reimbursement codes
• Coding E11.65 for Type 1 DM → Use E10.65 instead; incorrect code = denial or rework
• Billing E11.65 for every visit when only occasional high readings → Should be coded only if documentation supports “uncontrolled” status overall
• Over-coding multiple complications without documentation → Each diabetes complication code requires separate documentation support

Documentation Standards to Avoid Denials

✓ Best practices:

• Use phrase “poorly controlled” or “inadequately controlled” instead of ambiguous “uncontrolled” (clarifies direction: high vs low glucose)
• Include glucose/A1C values in provider’s assessment not just in lab results: “Type 2 diabetes, poorly controlled, A1C 8.9% today vs 7.4% six months ago”
• Document medication adherence explicitly: “Patient admits poor diet adherence and missed doses of glipizide due to cost” (explains why hyperglycemia present)
• List all current medications with doses and frequency
• When coding multiple complications, ensure EACH is separately documented in history of present illness or assessment
• Always include Z79.84 or Z79.4 with E11.65 to show medication management
• Sign and date all entries in chart
• For MA plans: Robust documentation of E11.65 + comorbidities maximizes HCC/RAF capture for accurate reimbursement

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Reimbursement & Claim Submission

Medicare Rates (2026 Estimate)

Service Setting	Typical CPT	Est. Medicare Reimbursement (2026)	Notes
Office visit	99213 -99215	$120-$180 per visit	Routine/urgent diabetes follow-up
Preventive office	99397 (age 50 -64)	$150-$200	Annual preventive visit including DM check
ED visit	99281 -99285	$150-$400	Acute hyperglycemic episode or DKA
Inpatient (first day)	99221 -99223	$250-$400	Hospital admission for uncontrolled DM/complications
Inpatient (subsequent)	99231 -99233	$150-$250/day	Daily management during hospitalization
A1C lab	83036	$20-$40	May be bundled into E/M in some settings
CGM download/review	95250	$30-$50 monthly	If patient on CGM

Note: Reimbursement varies by payer, MAC, locality, and patient insurance type (Medicare FFS vs MA). Always verify contractual rates pre-billing.

Claim Submission Checklist

• Primary diagnosis (E11.65) clearly documented and justified in chart
• Supporting elements present: A1C or glucose values, provider statement of “poorly controlled” or “uncontrolled,” medication list, adherence assessment
• Comorbidities coded if present (hypertension I10, dyslipidemia E78.5, obesity E66.9) for additional complexity/risk adjustment
• Z-codes included: Z79.84 (oral antidiabetic drugs) or Z79.4 (insulin) to indicate medication management
• CPT code matches service level: E/M complexity justified by severity of hyperglycemia, number of comorbidities, decision-making time
• If hospitalized: Confirm diagnosis warrants admission (severe hyperglycemia, DKA, HHS, complications) to support DRG assignment and higher reimbursement
• Prior authorization: Obtained if required by payer (check policy for insulin therapy, CGM, DSME referral)
• All required modifiers appended if applicable (e.g., -25 if significant E/M performed with procedure same day)

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References

[1] American Diabetes Association. (2025). Standards of Care in Diabetes - 2025 Revision. Diabetes Care, 48(Suppl 1), S1 -S325. https://doi.org/10.2337/dc25-S001

[2] Centers for Medicare & Medicaid Services. (2025). ICD-10-CM Official Guidelines for Coding and Reporting - 2025. Retrieved from https://www.cms.gov/files/document/2025-icd-10-cm-guidelines.pdf

[3] American Association of Clinical Endocrinologists & American College of Endocrinology. (2023). Comprehensive Type 2 Diabetes Management Algorithm - 2023. Endocrine Practice, 29(6), 1 -127. https://doi.org/10.1016/j.eprac.2023.04.001

[4] Centers for Medicare & Medicaid Services. (2025). Hierarchical Condition Categories (HCC) - 2026 Model Documentation Requirements. Retrieved from https://www.cms.gov/Medicare/Health-Plans/MedicareAdvantage/HCC-Model

[5] Defronzo, R. A., Ferrannini, E., Groop, L., et al. (2023). Type 2 diabetes. Nature Reviews Disease Primers, 11, 59. https://doi.org/10.1038/nrdp.2015.19

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Document Status: Complete for clinical reference & workplace use
Last Review: February 15, 2026
Next Update Due: February 2027 (2027 ICD-10-CM updates)
Specialty: Medical Coding / Endocrinology / Internal Medicine / Diabetes Management
Keywords: Type 2 diabetes, hyperglycemia, E11.65, uncontrolled diabetes, HCC 18, risk adjustment, medical coding