What is a good ICD-10 code for a patient with type 2 diabetes prescribed Ozempic (semaglutide)?

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ICD-10 Code for Ozempic (Semaglutide) in Type 2 Diabetes

Use ICD-10 code E11.9 (Type 2 diabetes mellitus without complications) as the primary diagnosis code for patients prescribed Ozempic (semaglutide), or use more specific E11.x codes if complications are present.

Primary Diagnosis Codes

  • E11.9 is the most appropriate code for uncomplicated type 2 diabetes when prescribing Ozempic 1
  • If the patient has established cardiovascular disease, use E11.65 (Type 2 diabetes mellitus with hyperglycemia) combined with the appropriate cardiovascular disease code, as Ozempic has proven cardiovascular benefits in this population 2
  • For patients with diabetic kidney disease, use E11.22 (Type 2 diabetes mellitus with diabetic chronic kidney disease) to reflect the renoprotective indication 3

Complication-Specific Codes

When complications are present, select the appropriate E11.x code that reflects the patient's condition:

  • E11.21: Type 2 diabetes with diabetic nephropathy (for patients with proteinuria or reduced eGFR) 3
  • E11.22: Type 2 diabetes with diabetic chronic kidney disease (for established CKD) 2
  • E11.51: Type 2 diabetes with diabetic peripheral angiopathy without gangrene 1
  • E11.65: Type 2 diabetes with hyperglycemia (when HbA1c is elevated above target) 4

Additional Supporting Codes

For cardiovascular indications, add secondary diagnosis codes to support medical necessity:

  • I25.10: Atherosclerotic heart disease of native coronary artery without angina pectoris 2
  • I50.9: Heart failure, unspecified (if heart failure is present) 2
  • Z86.73: Personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits 2

For obesity management, which is relevant given Ozempic's weight loss effects:

  • E66.01: Morbid (severe) obesity due to excess calories (BMI ≥40) 4, 5
  • E66.9: Obesity, unspecified (BMI 30-39.9) 4, 5

Clinical Context for Code Selection

The American Diabetes Association guidelines establish that semaglutide (Ozempic) is indicated for patients with type 2 diabetes who have established atherosclerotic cardiovascular disease or are at high cardiovascular risk 2. The SUSTAIN-6 trial demonstrated a 26% reduction in major adverse cardiovascular events (HR 0.74,95% CI 0.58-0.95) 2.

For renal protection, recent evidence shows significant renoprotective effects, with one case report demonstrating reduction in urine albumin-to-creatinine ratio from 267 mg/g to 34 mg/g over 12 months 3. This supports using diabetic nephropathy codes (E11.21 or E11.22) when kidney involvement is present.

Important Documentation Requirements

  • Document baseline HbA1c (typically ≥7.0% for initiation) 4, 6
  • Record BMI if obesity is a treatment consideration (mean BMI in trials was 38.6 kg/m²) 4
  • Note cardiovascular disease status, as this strengthens medical necessity 2
  • Document failure or contraindication to metformin if applicable 2

Common Pitfalls to Avoid

  • Do not use E10.x codes (Type 1 diabetes codes) for patients on Ozempic, as it is not indicated for type 1 diabetes 1, 6
  • Avoid using only E11.9 when specific complications exist, as more specific codes better reflect medical necessity and the patient's condition 1
  • Do not forget secondary diagnosis codes for cardiovascular disease or obesity when these are treatment indications, as they support prior authorization requirements 2

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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