In our Coding Case Studies, we will explore the correct coding for a specific condition based on a hypothetical clinical scenario. This scenario involves a patient presenting with symptoms of type 2 diabetes; see if you can choose the correct codes.
Documentation Coding Requirements
When documenting diabetes, include the following:
Type: Type 1 or Type 2
- Due to underlying condition
- Drug or chemical induced diabetes mellitus
- Diabetes mellitus in pregnancy, childbirth, and the puerperium
- With or without complication
- With or without coma
- Eye: Left, right, bilateral
Clinical Scenario
Chief Complaint:
Patient presents with issues with palpitations and “not feeling right”
- Palpitations
- Diabetes
- Hyperlipidemia
- Nicotine Dependence
Review of Systems
HENT: Negative.
Eyes: Negative.
Respiratory: Positive for shortness of breath.
Cardiovascular: Positive for palpitations.
Gastrointestinal: Negative.
Endocrine: Negative.
Genitourinary: Negative.
Musculoskeletal: Negative.
Skin: Negative.
Allergic/Immunologic: Negative.
Neurological: Positive for weakness.
Hematological: Negative.
Psychiatric/Behavioral: Negative.
All other systems reviewed and are negative.
Social History
Smoking status:
- Current Every Day Smoker
- Types: Cigarettes
Physical Exam
Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished.
HENT:
- Head: Normocephalic and atraumatic.
- Right Ear: External ear normal.
- Left Ear: External ear normal.
- Nose: Nose normal.
- Mouth/Throat: Oropharynx is clear and moist.
Eyes: Conjunctivae and EOM are normal. Pupils are equal, round, and reactive to light.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses.
Pulmonary/Chest: Effort normal and breath sounds normal.
Abdominal: Soft. Bowel sounds are normal.
Genitourinary Comments: sees Gyn
Neurological: She is alert and oriented to person, place, and time. She has normal reflexes.
Skin: Skin is warm and dry.
Psychiatric: She has a normal mood and affect. Her behavior is normal. Judgment and thought content normal.
Assessment and Plan
1. Palpitations ECG 12 lead
2. DM (diabetes mellitus) POCT hemoglobin A1c: 5.7 Continue metFORMIN (GLUCOPHAGE) 500 MG
3. Hyperlipidemia associated with type 2 diabetes mellitus
4. Tobacco abuse discussed quitting with patient
Has 4 of 5 risk factors for CAD: DM, Lipids, Fam HX, Tob
Check Calcium Score, if positive will needs cardiology eval
Correct Diagnosis Codes
R00.2: Palpitations
E11.69: Type 2 diabetes mellitus with other specified complication
E78.5: Hyperlipidemia, unspecified
F17.210: Nicotine dependence, cigarettes, uncomplicated
Z79.84: Long term (current) use of oral hypoglycemic drugs
ICD-10 Codes for Type 2 Diabetes Mellitus
Type 2 diabetes mellitus with:
E11.10: ketoacidosis without coma
E11.11: ketoacidosis with coma
E11.21: diabetic nephropathy
E11.22: diabetic chronic kidney disease 1
E11.311: unspecified diabetic retinopathy with macular edema 2
E11.319: without macular edema 2
E11.3211: mild nonproliferative diabetic retinopathy with macular edema, right eye
- E11.3212: left eye
- E11.3213: bilateral
- E11.3219: unspecified eye
E11.3291: mild nonproliferative diabetic retinopathy without macular edema, right eye
- E11.3292: left eye
- E11.3293: bilateral
- E11.3299: unspecified eye
E11.3311: moderate nonproliferative diabetic retinopathy with macular edema, right eye
- E11.3312: left eye
- E11.3313: bilateral
- E11.3319: unspecified eye
E11.3391: moderate nonproliferative diabetic retinopathy without macular edema, right eye
- E11.3392: left eye
- E11.3393: bilateral
- E11.3399: unspecified eye
E11.3411: severe nonproliferative diabetic retinopathy with macular edema, right eye
- E11.3412: left eye
- E11.3413: bilateral
- E11.3419: unspecified eye
E11.3491:severe nonproliferative diabetic retinopathy without macular edema, right eye
- E11.3492: left eye
- E11.3493: bilateral
- E11.3499: unspecified eye
E11.3511: proliferative diabetic retinopathy with macular edema, right eye
- E11.3512: left eye
- E11.3513: bilateral
- E11.3519: unspecified eye
E11.3521: proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
- E11.3522: left eye
- E11.3523: bilateral
- E11.3529: unspecified eye
E11.3531: proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
- E11.3532: left eye
- E11.3533: bilateral
- E11.3539: unspecified eye
E11.3541: proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
- E11.3542: left eye
- E11.3543: bilateral
- E11.3549: unspecified eye
E11.3551: stable proliferative diabetic retinopathy, right eye
- E11.3552: left eye
- E11.3553: bilateral
- E11.3559: unspecified eye
E11.3591: proliferative diabetic retinopathy without macular edema, right eye
- E11.3592: left eye
- E11.3593: bilateral
- E11.3599: unspecified eye
E11.37X1: diabetic macular edema, resolved following treatment, right eye
- E11.37X2: left eye
- E11.37X3: bilateral
- E11.37X9: unspecified eye
E11.39: other diabetic ophthalmic complication 3
E11.40: diabetic neuropathy, unspecified
E11.41: diabetic mononeuropathy
E11.42: diabetic polyneuropathy
E11.43: diabetic autonomic (poly)neuropathy
E11.44: diabetic amyotrophy
E11.49: other diabetic neurological complication
E11.51: diabetic peripheral angiopathy without gangrene
E11.52: diabetic peripheral angiopathy with gangrene
E11.59: other circulatory complications
E11.610
with diabetic neuropathic arthropathy
E11.618: other diabetic arthropathy
E11.620: diabetic dermatitis
E11.621: foot ulcer 4
E11.622: other skin ulcer 5
E11.628: other skin complications
E11.630: periodontal disease
E11.638: other oral complications
E11.641: hypoglycemia with coma
E11.649: hypoglycemia without coma
E11.65: hyperglycemia
E11.69: other specified complication 6
E11.8: unspecified complications
E11.9: without complications
NOTES:
For all codes, use additional code to identify control using:
- insulin (Z79.4)
oral antidiabetic drugs (Z79.84)
oral hypoglycemic drugs (Z79.84)
1 Use additional code to identify stage of chronic kidney disease (N18.1-N18.6)
2 One of the following 7th characters is to be assigned to codes in subcategories E11.32, E11.33, E11.34, E11.35, and E11.37 to designate laterality of the disease: right eye, left eye, bilateral, unspecified eye.
3 Use additional code to identify manifestation, such as: diabetic glaucoma (H40-H42)
4 Use additional code to identify site of ulcer (L97.4-, L97.5-)
5 Use additional code to identify site of ulcer (L97.1-L97.9, L98.41-L98.49)
6 Use additional code to identify complication
Renee Dowling is a billing and coding consultant with VEI Consulting in Indianapolis.
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Originally Published On: Medical Economics
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