E11.65

🩺 ICD-10 CM 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

---

Short Definition

ICD-10 CM 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. The code carries HCC 18 weight (0.368) in risk-adjustment payment models, indicating moderate risk elevation for the Medicare Advantage population.

---

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

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)

Mechanisms causing uncontrolled hyperglycemia in Type 2 DM:

• 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:

• 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)

Chronic complications from sustained hyperglycemia:

• 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:

• 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. 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):

• 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

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)

---

HCC (Hierarchical Condition Category) Status

E11.65 HCC Status: YES - HCC Category 18

HCC Category 18 Details:

• 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

Why E11.65 is HCC-weighted:

• 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:

• 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

---

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

✗ 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:

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

---

Documentation Requirements (For Accurate Coding)

Critical Elements to Document

Provider documentation MUST include:

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.

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?

---

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)

---

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:

• 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

---

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)

---

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

---

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)

---

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

---

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