Coding scenario: Type 2 diabetes

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.