With the 2025 ICD-10-CM updates, came new codes used to identify the level of hypoglycemia. Although these are optional to code, they can help provide additional information in the record about the patient.
Hypoglycemia has been expanded to include three levels. What do these levels look like?
Level 1 (Mild): BG level of between 54mg/dL and 70mg/dL
For reference and general understanding, symptoms might include hunger, nervousness, shaking, sweating, cold clammy skin, headache, and pounding heartbeat.
Level 2 (Moderate): BG level is less than 54mg/dL
For reference and general understanding, symptoms might include dizziness, sleepiness, weakness, irritability, trouble speaking, and confusion.
Level 3 (Severe): This level describes someone who is unable to function.
For reference and general understanding, symptoms may include seizures, convulsions, loss of consciousness, and coma.
When coding, if the information for the level is not provided and the provider only documents hypoglycemia, then E16.2 is what would be assigned.
In the event that hypoglycemia is documented, along with the level, you would assign:
E16.2 for hypoglycemia
E16.A- for the level documented as an additional code.
Sources:
www.endocrine.org
CMS ICD-10-CM TABULAR LIST of DISEASES and INJURIES 2025 Addenda
Hypoglycemia has been expanded to include three levels. What do these levels look like?
Level 1 (Mild): BG level of between 54mg/dL and 70mg/dL
For reference and general understanding, symptoms might include hunger, nervousness, shaking, sweating, cold clammy skin, headache, and pounding heartbeat.
Level 2 (Moderate): BG level is less than 54mg/dL
For reference and general understanding, symptoms might include dizziness, sleepiness, weakness, irritability, trouble speaking, and confusion.
Level 3 (Severe): This level describes someone who is unable to function.
For reference and general understanding, symptoms may include seizures, convulsions, loss of consciousness, and coma.
When coding, if the information for the level is not provided and the provider only documents hypoglycemia, then E16.2 is what would be assigned.
In the event that hypoglycemia is documented, along with the level, you would assign:
E16.2 for hypoglycemia
E16.A- for the level documented as an additional code.
Sources:
Severe Hypoglycemia
When hypoglycemia symptoms are left untreated they can cause life threatening consequences.
www.endocrine.org