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
Clinical Scenario Chief Complaint: Patient presents with issues with palpitations and "not feeling right"
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:
Physical Exam Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished. HENT:
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
E11.3291: 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 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:
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. What is the ICDICD-10 code E78. 5 for Hyperlipidemia, unspecified is a medical classification as listed by WHO under the range - Endocrine, nutritional and metabolic diseases .
What is the ICDICD-10 code E11. 69 for Type 2 diabetes mellitus with other specified complication is a medical classification as listed by WHO under the range - Endocrine, nutritional and metabolic diseases .
What is E78 2 mixed hyperlipidemia?ICD-10 code E78. 2 for Mixed hyperlipidemia is a medical classification as listed by WHO under the range - Endocrine, nutritional and metabolic diseases .
What is the ICDICD-10-CM E11. 65 converts approximately to: 2015 ICD-9-CM 250.80 Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled.
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