When documenting complicated diabetes conditions, link the etiology (diabetes) with the manifestation (condition caused by the patient’s diabetes), using as many codes as needed to identify the patient’s conditions. Conditions will not be assumed to be related or causative without proper linking language.
- Report the complication using cause and effect language to clearly relate the two conditions.
- Use language such as “due to” or “with” to link conditions.
- Include the following in combination codes:
- Type of diabetes mellitus
- Body system affected
- Complications affecting that particular body system
Here is an example of appropriate documentation that shows the concept of MEAT was used to support the combination diabetic diagnosis:
Type 2 diabetes mellitus with diabetic chronic kidney disease (E11.22)
“Renal disorder due to type 2 diabetes mellitus. Last A1C: 11/8/17 7.2, DUE. Last microalbumin: 11/2017 wnl. Foot exam: 11/8/17, OK. Eye exam: neg in 10/2017.
Takes: Metformin ER 500MG BID, Novolog 70/30, varying doses due to few low BG, esp at night.
Hemoglobin A1C 7.8 on 5/15/18. This is an increase from February when it was 7.3. She feels blood sugars are uncontrolled related to chronic diarrhea and stress associated with this.”
Note that two of the most commonly under-documented diabetes mellitus diagnosis codes are:
- Type 2 diabetes mellitus with other circulatory complication (E11.59)
- Requires circulatory complication to be documented and reported
- Type 2 diabetes mellitus with other specified complication (E11.49)
- Requires other specified complication to be documented and reported
Your coding consultant is here to help. Contact us at CodingCounts@healthalliance.org.
ICD-10-CM Expert 2017
2018 AAPC study guide: CRC