ICD-10 Code E11.9

E11.9 is a billable/specific ICD-10-CM code designated for "Type 2 diabetes mellitus without complications." This code is part of the endocrine, nutritional, and metabolic diseases chapter (E00-E89), specifically under category E11 Type 2 diabetes mellitus. It is used for clinical diagnosis and billing purposes to indicate that a patient has Type 2 diabetes that is currently not associated with any clinical complications typically linked to the disease.

The use of E11.9 indicates that the patient has been diagnosed with Type 2 diabetes mellitus, a condition characterized by insulin resistance and relative insulin deficiency. Code E11.9 is used when this condition has not yet led to health complications, such as neuropathy, nephropathy, retinopathy, or cardiovascular issues. Management focuses on monitoring blood sugar levels to prevent complications through lifestyle modifications, medication, and regular check-ups.

Typically, Type 2 diabetes itself might be asymptomatic in early stages and is often diagnosed on routine testing. However, patients may experience:

Other related ICD-10-CM codes include:

E11.9 should be used for billing purposes when a provider lists in the assessment portion of the note that a patient is diagnosed with Type 2 diabetes mellitus and has not developed any of the related diabetic complications. It is important to document the presence of any associated diabetic complications to avoid incorrectly assigning this code.

Instructional notes and/or guidelines with E11.9 

Accurate documentation is beneficial when using the E11.9 code, including details of any tests performed. It is crucial to periodically re-evaluate the patient's condition to update the coding if complications arise, based on the provider's assessment.

If the type of diabetes mellitus is not documented in the medical record, the default is Type 2 diabetes mellitus. 

Additional code(s) from category Z79 should be assigned with E11.9 to identify the long-term (current) use of insulin, oral hypoglycemic drugs, or injectable non-insulin antidiabetic:

E11.9 is used to identify cases of Type 2 diabetes mellitus without complications. Proper use of this code facilitates not only appropriate billing but also helps in guiding the management of the disease to prevent the onset of complications, thus enhancing the quality of care provided to patients.