August 7, 2025

New ICD-10-CM Code E11.A: Type 2 Diabetes Mellitus Without Complications in Remission

Background and FY 2026 Update

With the 2026 IPPS Proposed Final Rule comes a new diabetes code, E11.A, Type II diabetes mellitus without complications in remission. This is a non-CC/MCC and is assigned to MDC 10. 


ICD-10-CM Official Coding Guidance for E11.A

Section I.C.4.a.1.(b) - “Code E11.A, Type 2 diabetes mellitus without complications in remission, is assigned based on provider documentation that the diabetes mellitus is in remission. If the documentation is unclear as to whether the Type 2 diabetes mellitus has achieved remission, the provider should be queried. For example, the term “resolved” is not synonymous with remission.” 


Clinical Criteria for Diabetes Mellitus in Remission

Note* - Remission does not mean cure. Ongoing monitoring is essential as relapse is possible. 


1. Prior Diagnosis of Diabetes Mellitus 

  • Documented history of type 2 diabetes mellitus, diagnosed using standard criteria: 
  • HbA1c ≥ 6.5% 
  • Fasting plasma glucose ≥ 126 mg/dL 
  • 2-hour plasma glucose ≥ 200 mg/dL during an OGTT 
  • Random plasma glucose ≥ 200 mg/dL with classic symptoms 

 

2. Normal or Controlled Glucose Levels Without Medications 

  • The patient is not taking any antidiabetic medications (oral agents, insulin, or non-insulin injectables). 
  • Glycemic control is sustained through lifestyle modifications, such as diet and exercise. 
  • HbA1c < 6.5%, and sometimes < 6.0%, on two occasions at least 6 months apart without pharmacologic therapy. 

 

3. Duration of Remission 

  • Partial remission: HbA1c < 6.5% and fasting glucose 100–125 mg/dL for at least 1 year without medications. 
  • Complete remission: HbA1c in the normal range (<5.7%) and fasting glucose <100 mg/dL for at least 1 year. 
  • Prolonged remission: Complete remission lasting ≥5 years. 

 


4. Documentation Must Include 

  • Clear statement that diabetes is in remission or resolution. 
  • No current use of diabetes medications. 
  • Current HbA1c values. 
  • Lifestyle interventions being used. 
  • Absence of ongoing diabetic complications (or if present, they are noted as sequelae) 

 


5. What about Type I diabetes? Is remission associated? 

  • “Honeymoon Phase” vs. Remission 
  • Some individuals newly diagnosed with type 1 diabetes may experience a "honeymoon phase": 
  • This is a temporary period (weeks to months) where insulin needs to decrease and blood glucose levels may normalize. 
  • However, this is not true remission, as the autoimmune process continues and insulin dependence eventually returns. 

 

 

Clinical Scenario

Dr. Doctor, 


Documentation in your visit note indicates the patient has a documented history of type 2 diabetes mellitus, but current labs show: 

 

  • HbA1c: 5.6% 
  • No diabetes medications (e.g., insulin, metformin) currently prescribed 
  • Patient reports lifestyle changes (e.g., diet and weight loss) 
  • No hyperglycemia documented during this admission or recent visits 

 


Query 

Based on the clinical picture, can you please clarify the patient’s current diabetic status? 


☐ Type 2 diabetes mellitus – continue to document and treat as active 

☐ History of type 2 diabetes mellitus, currently in remission (no medications, normal glucose values) 

☐ Other: ________________ 


 

Jessica Lutz, MBA, RHIA, CCS, Senior Consultant, Audit at UASI

Jessica Lutz, MBA, RHIA, CCS 
AHIMA Microcredential: Auditing: Inpatient Coding   

Senior Consultant, Audit at UASI

 

Jessica Lutz serves as a Senior Consultant in Auditing at UASI and is recognized for her ICD-10-CM/PCS expertise and inpatient coding background. She shares coding tips from an auditor’s perspective, highlighting common pitfalls and practical ways coders and CDI teams can improve accuracy and documentation quality. 


Works Cited:

American Diabetes Association. (2024). Standards of care in diabetes—2024. Available at:
https://professional.diabetes.org/standards-of-care


American Diabetes Association. (2024). Glycemic goals and hypoglycemia. Available at:
https://diabetesjournals.org/care/article/47/Supplement_1/S111/153951/6-Glycemic-Goals-and-Hypoglycemia-Standards-of


Buse, J. B., et al. (2009). How do we define cure of diabetes? Available at:
https://pubmed.ncbi.nlm.nih.gov/19875608/


Centers for Medicare & Medicaid Services. (2026). ICD-10-CM Official Guidelines for Coding and Reporting. Available at:
https://www.cms.gov


Centers for Medicare & Medicaid Services. (2026). Inpatient prospective payment system (IPPS) proposed rule. Available at:
https://www.cms.gov


MRI brain scans illustrating symptoms of PRES with title text overlay.

Symptoms of PRES: Diagnosis, Treatment, and ICD-10-CM Coding Guidance

December 9, 2025
Learn the symptoms of PRES, key treatment considerations, ICD-10-CM code I67.83, and documentation tips for CDI and accurate DRG assignment.
Microscopic immune cells interacting in cellular environment, illustrating immune effector activity

CDI Tip: ICANS Grading and Accurate Documentation

By Katie Curry • December 1, 2025
Understand ICANS documentation and ICD-10 coding with guidance on the ICANS grading system, ICE score, clinical indicators, and CAR T-cell neurotoxicity.
Fingerstick blood glucose test being performed, illustrating screening and monitoring practices for gestational diabetes.

Gestational Diabetes

By Katie Curry • November 3, 2025
Gestational Diabetes
Clinician pointing to anatomical kidney model illustrating acute kidney injury.

Acute Kidney Injury (AKI)

By Katie Curry • October 20, 2025
Learn how to identify, document, and code acute kidney injury (AKI), including diagnostic criteria, staging, ICD-10-CM guidance, and CDI query considerations.
Blurred hospital scene symbolizing CDI review of firearm injury intent reporting.

Reporting of Firearm Injury Intent

By Katie Curry • September 30, 2025
Learn how firearm injury intent is documented and reported in ICD-10-CM, including intent categories, external cause codes, and documentation considerations.
Title image for the ventricular standstill clinical documentation and coding overview

Ventricular Standstill

By Katie Curry • September 22, 2025
Learn how ventricular standstill is documented and coded, including clinical indicators, ICD-10-CM guidance, and common documentation considerations.
Title image for neurostorming (PSH) documentation and coding

CDI TIP: Neuro Storm

By Katie Curry • September 7, 2025
Learn how neurostorming, also known as paroxysmal sympathetic hyperactivity (PSH), is documented and coded using ICD-10-CM guidance.

Neonatal Encephalopathy

By Katie Curry • July 9, 2025
Definition: Neonatal encephalopathy (NE) is a clinically defined syndrome of disturbed neurologic function in the earliest days of life in a term or late preterm infant, manifested by difficulty with initiating and maintaining respiration, depression of tone and reflexes, subnormal level of consciousness, and often seizures. Clinical presentation: Low APGAR scores and/or weak/absent cry in the delivery room. Hyperalert, irritable, lethargic, obtunded. Decreased spontaneous movements, poor tone, blunted or absent primitive reflexes, seizure activity. Breathing and/or feeding difficulties. Documentation Tips: The CDS should review to identify the underlying etiology . (e.g., hypoxic-ischemic event, infection, metabolic disorder). Review clinical indicators that may indicate associated conditions , such as seizures, abnormal imaging, acidosis, or multi-organ dysfunction. Review the documentation for the timing of onset (e.g., at birth, delayed). Common clinical indicators include low APGAR scores, need for resuscitation, abnormal tone, or altered level of consciousness.  ICD-10-CM Coding: P91.811, Neonatal encephalopathy in diseases classified elsewhere P91.819, Neonatal encephalopathy, unspecified Use when the type or etiology of NE is not documented Query Example: To the Attending Neonatologist: Documentation in the medical record indicates the newborn infant delivered from mother with placental abruption demonstrates seizures, abnormal muscle tone, low APGAR scores, and required resuscitation at birth. Imaging showed evidence of cerebral edema. The diagnosis of “neonatal encephalopathy” was documented in the assessment. Query: Based on the clinical indicators, can you clarify the type and cause of the encephalopathy in this newborn? Please select the most appropriate option below or specify another diagnosis: Neonatal encephalopathy due to Hypoxic-ischemic encephalopathy (HIE) Neonatal encephalopathy due to other etiology (please specify) Other (please specify): __________

CDI Tip: Tumor Lysis Syndrome

By Katie Curry • May 12, 2025
Definition: Tumor lysis syndrome (TLS) is an oncologic emergency caused by massive tumor cell lysis and the release of large amounts of potassium, phosphate, and uric acid into the systemic circulation. Deposition of uric acid and/or calcium phosphate crystals in the renal tubules can result in acute kidney injury.
Provider with stethoscope, representing clinical evaluation and diagnosis of SIADH and related endocrine fluid imbalances.

Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)

By Brandon Losacker • April 17, 2025
Syndrome of Inappropriate Antidiuretic Hormone (SIADH) occurs when the pituitary gland releases excessive antidiuretic hormone (ADH) , leading the body to retain fluid and dilute sodium levels in the bloodstream. This condition causes hyponatremia and hypo-osmolality , often triggering a complex clinical picture. What Causes SIADH? SIADH can develop in response to several underlying conditions or external factors: CNS disturbances: Stroke, hemorrhage, infection, and trauma can trigger abnormal ADH release. Cancer: Especially small cell lung cancer, extrapulmonary small cell carcinomas, head and neck cancers, and olfactory neuroblastomas. Medications: SSRIs, NSAIDs, opiates, some antineoplastic drugs, ciprofloxacin, haloperidol, and high-dose imatinib. Surgery: Often linked to pain response. Hormonal deficiencies: Including hypothyroidism and hypopituitarism. Exogenous hormone use: Vasopressin, desmopressin, and oxytocin. HIV infection Hereditary SIADH Diagnostic Criteria: Schwartz and Bartter Clinical Framework A diagnosis of SIADH typically includes: Serum sodium < 135 mEq/L Serum osmolality < 275 mOsm/kg Urine sodium > 40 mEq/L Urine osmolality > 100 mOsm/kg Normal skin turgor and blood pressure (absence of clinical volume depletion) Exclusion of other hyponatremia causes Correction of sodium levels via fluid restriction Important Note: Code only the SIADH, not the hyponatremia, as hyponatremia is considered integral to the disease process . Clinical Scenario A 68-year-old male presents to the ED with confusion , nausea , and a 12-pound weight gain over the past week. He was diagnosed with small cell lung cancer two months ago. Vitals: BP: 160/90 mmHg HR: 110 bpm Labs: Serum sodium: 122 mEq/L Serum osmolality: Decreased Urine: Elevated osmolality and high sodium concentration Indicators Suggestive of SIADH Hyponatremia: Sodium level of 122 mEq/L Diluted Serum Osmolality: From water retention Concentrated Urine: High osmolality and sodium levels despite low serum sodium Recent Weight Gain: 12 lbs in one week, pointing to fluid overload Underlying Malignancy: Small cell lung cancer is a well-known cause of ectopic ADH production Documentation Tips 1. Accurate Diagnosis Clearly state “SIADH” and link it to the underlying cause , such as cancer. 2. Clinical Findings Review provider and nursing notes for symptoms like confusion, nausea, and fluid retention. Confirm vital signs and weight gain. Include lab values: sodium, serum/urine osmolality, and urine sodium. 3. Treatment Plan Document fluid restriction orders . Check MAR for medications such as vasopressin receptor antagonists . Note any improvements in symptoms and lab values after treatment. Tip: High blood glucose can artificially lower serum sodium levels. Use a sodium correction calculator to determine the true sodium level. References Centers for Medicare and Medicaid Services. (2024). ICD-10-CM Official Coding Guidelines. Available here: cms.gov Pinson, R., & Tang, C. (2024). The CDI Pocket Guide. Available here: cdiplus.com Prescott, L., & Manz, J. (2024). ACDIS CDI Pocket Guide. Available here: https://acdis.org/ Sterns, R. (2024). Pathophysiology and etiology of SIADH. UpToDate. Yasir, M., & Mechanic, O.J. (2023). Syndrome of Inappropriate Antidiuretic Hormone Secretion. StatPearls Publishing.
Show More