Coding scenario: Type 2 diabetes

November 2, 2020
Renee Dowling

See if you can choose the correct codes.

In the medical billing and coding field, getting paid requires accurate documentation and selecting the correct codes.

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.