E11.65
BillableType 2 diabetes mellitus with hyperglycemia
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is E11.65 an HCC code?
Yes. E11.65 maps to Diabetes without Complication under the CMS-HCC V28 risk adjustment model (and Diabetes with Chronic Complications under V24).
HCC Category Mapping
RAF weights shown are the community, non-dual, aged base weights from the CMS risk adjustment model file. Actual per-patient RAF contribution depends on member segment, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains in use during the transition and for historical data.
MEAT Criteria for E11.65
For E11.65 to count as a valid HCC diagnosis in a given encounter, the provider's documentation must show MEAT: Monitor, Evaluate, Assess, or Treat. A diagnosis from a prior year does not carry forward automatically — it has to be re-documented and supported each calendar year.
- MMonitor: signs, symptoms, disease progression, or lab trending documented in the note
- EEvaluate: test results, medication response, or physical findings reviewed by the provider
- AAssess: explicit mention in the assessment or plan with acknowledgment of status
- TTreat: medication, referral, procedure, therapy, or counseling tied to the diagnosis
Only one of M/E/A/T is required to support the code, but the documentation must be specific enough to show that the provider actually addressed E11.65 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
E11.65 is the ICD-10-CM diagnosis code for type 2 diabetes mellitus with hyperglycemia. Type 2 diabetes with abnormally high blood sugar levels that are not controlled by current treatment. E11.65 sits in the ICD-10-CM chapter for endocrine, nutritional and metabolic diseases (e00-e89), within the section covering diabetes mellitus (e08-e13).
Under the CMS-HCC V28 risk adjustment model, E11.65 maps to Diabetes without Complication (HCC 38) with a community, non-dual, aged base RAF weight of 0.450. Under the older CMS-HCC V24 model, E11.65 maps to Diabetes with Chronic Complications (HCC 18) with a community, non-dual, aged base RAF weight of 0.302. V28 is the CMS-HCC risk adjustment model that reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition.
Document the specific blood glucose readings or HbA1c values to support hyperglycemia diagnosis. Because E11.65 maps to a payment HCC, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's Medicare Advantage risk adjustment score. When documentation is ambiguous, coders should issue a provider query rather than assume the highest-specificity variant.
HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for E11.65 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Document the specific blood glucose readings or HbA1c values to support hyperglycemia diagnosis
- •Distinguish from uncontrolled diabetes by confirming elevated glucose levels are present
Clinical Significance
Type 2 diabetes mellitus with hyperglycemia indicates persistently elevated blood glucose that is inadequately controlled by current therapy, including oral medications, non-insulin injectables, or insulin. Chronic hyperglycemia drives the development and progression of all microvascular and macrovascular diabetic complications. This code signals the need for treatment intensification through medication adjustment, lifestyle modification, or specialist referral.
Documentation Requirements
- ✓The provider must document hyperglycemia in the context of Type 2 diabetes, including specific blood glucose readings or hemoglobin A1c values demonstrating inadequate control.
- ✓Current medication regimen, adherence assessment, and planned therapeutic changes should be recorded.
- ✓The documentation should distinguish hyperglycemia from diabetic ketoacidosis or hyperosmolar state, which are more severe conditions.
Commonly Confused Codes
- •E11.00/E11.01 (hyperosmolarity) and E11.10/E11.11 (ketoacidosis) represent more severe metabolic decompensation and should be used when those criteria are met.
- •E11.9 (without complications) is used when no complications including hyperglycemia are documented.
- •E11.649 (hypoglycemia) is the opposite metabolic derangement.
- •Z79.84 (long-term use of oral hypoglycemic drugs) is a status code, not a complication code.