Type 2 Diabetes Mellitus without Complications, In Remission

A patient with type 2 diabetic chronic kidney disease (CKD), stage 2, has a history of bariatric surgery due to morbid obesity. The patient has lost a significant amount of weight and no longer requires antidiabetic medication. The provider documented that the patient’s diabetes is in remission and that the CKD is stable. Is it appropriate to assign a code for diabetes in remission in this scenario? ...

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Note:  The following article synopsis was NOT provided by the AHA. It was created by Find-A-Code/innoviHealth.

Article Overview

This premium article focuses on how a newly created ICD-10-CM code for type 2 diabetes mellitus in remission fits into clinical documentation and coding. It discusses the general clinical concept of remission, the importance of provider documentation, the need to clarify ambiguous wording, and the interaction between remission status and diabetes-related complications. It is intended for coders, coding auditors, CDI professionals, and clinicians involved in diabetes documentation.

Why This Topic Matters

Accurate identification of diabetes remission affects diagnosis coding, documentation review, and whether other diabetes-related codes must be reported instead. The article helps readers understand when remission language is supported, when clarification is needed, and why complication status changes code assignment considerations.

What You Will Learn

  • How type 2 diabetes mellitus in remission is described in the coding context
  • What kinds of documentation support a remission status
  • Why clarification may be needed when remission is not clearly documented
  • How the presence of diabetes-related complications affects the use of the remission code
  • General factors that may be associated with diabetes remission and relapse monitoring

Who Should Read This

  • Medical coders
  • Coding auditors
  • Clinical documentation integrity professionals
  • Physicians and other providers documenting diabetes status
  • Revenue cycle and compliance staff

Codes Discussed


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