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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
Patient presents with issues with palpitations and "not feeling right"
Review of Systems
Respiratory: Positive for shortness of breath.
Cardiovascular: Positive for palpitations.
Neurological: Positive for weakness.
All other systems reviewed and are negative.
Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished.
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
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
E11.3291: mild nonproliferative diabetic retinopathy without macular edema, right eye
E11.3311: moderate nonproliferative diabetic retinopathy with macular edema, right eye
E11.3391: moderate nonproliferative diabetic retinopathy without macular edema, right eye
E11.3411: severe nonproliferative diabetic retinopathy with macular edema, right eye
E11.3491:severe nonproliferative diabetic retinopathy without macular edema, right eye
E11.3511: proliferative diabetic retinopathy with macular edema, right eye
E11.3521: proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E11.3531: proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E11.3541: proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E11.3551: stable proliferative diabetic retinopathy, right eye
E11.3591: proliferative diabetic retinopathy without macular edema, right eye
E11.37X1: diabetic macular edema, resolved following treatment, right 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
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
E11.69: other specified complication 6
E11.8: unspecified complications
E11.9: without complications
For all codes, use additional code to identify control using:
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.