Type 2 Diabetes Mellitus in Remission

This month, “In the kNOW” is going to look at a brand-new coding guideline that went into effect October 1, 2025 which addresses type 2 diabetes mellitus in remission.

This is the actual guideline:

Guideline I.C.4.a.1.b

(b) Type 2 diabetes mellitus in remission

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.

Key pieces as takeaways from this guideline are:

• Remission must be documented
• Ambiguity must be queried
• Resolved does not equal remission
  

Let’s take a little deeper look at each of these beginning with documentation of remission. When would diabetes be considered in remission? Being in remission would indicate that a patient with type 2 diabetes has reached normal glucose levels (<6.5% A1C) and been able to maintain them for at least 3 months without needing medication. Remission can be obtained when a patient has significant weight loss, such as following bariatric surgery, or works diligently at healthy lifestyle choices including a proper diet and regular exercising. 

It is important to remember that the terms “history of” and “resolved” do not automatically translate to “in remission”. When in doubt, query the provider. 

Here is a look at the Tabular Index entry for the new diabetes in remission code: 

E11.A Type 2 diabetes mellitus without complications in remission

Excludes1: type 2 diabetes mellitus, with complications (E11.0-E11.8)

type 2 diabetes mellitus, without complications not in remission (E11.9)

Keeping this in mind, let’s look at the following scenario and how it should be coded.

A previously morbidly obese patient had bariatric surgery and achieved a 120 lb. weight loss. He also has a diagnosis of type 2 diabetic chronic kidney disease (CKD) stage 2. On this office visit the provider documents that the patient no longer needs antidiabetic meds with the diabetes found to be in remission. Documentation by the provider states the CKD is stable.

The code assignment should be:

E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease

N18.2 Chronic kidney disease, stage 2 (mild)

Z98.84 Bariatric surgery status

Even though the provider has documented that the diabetes is in remission, by following the Excludes1 note in the Tabular Index at E11.A, we can see that if there are complications of the diabetes, we cannot assign E11.A. According to the 4th Quarter 2025 Coding Clinic, the codes above would be correct. 

 

Now you are In the kNOW!!

 

About the Author

Dianna Foley, RHIA, CCS, CDIP, CHPS, has 25 years of HIM experience. She earned her bachelor’s degree from the University of Cincinnati and holds RHIA, CHPS, CDIP, and CCS certifications from AHIMA. Dianna’s an AHIMA-approved ICD-10-CM/PCS trainer, an AHIMA-published author, a participant in AHIMA credential item writing and exam development, and served on the AHIMA Nominating Committee. Dianna has held various HIM positions and is now an independent coding consultant. She previously served as a program director for Medical Coding and HIT. She presents on coding topics at the national, state, and regional levels and serves as OHIMA’s Education Coordinator.