Coding case study: Type 2 Diabetes follow-up

In the medical billing and coding field, getting paid requires accurate documentation and selecting the correct codes. In our Coding Case Studies, we explore the correct coding for a specific condition based on a hypothetical clinical scenario. This scenario involves a patient presenting for a follow-up visit with symptoms of Type 2 Diabetes. See if you can choose the correct codes.

Clinical Scenario

Chief Complaint

Patient, a 52-year-old male, came to the office for follow up of Type 2 diabetes mellitus (T2DM), hyperlipidemia, hypertension, urine micro albumin. Patient reports he was diagnosed with T2DM at age 45. Patient has been on insulin since 2010. Since last visit, patient reports blood sugars are stable.

Current Treatment:

Current diabetic regimen includes Tresiba 36 units daily and Xigduo (5/1000mg) 2 tab daily.

Reviewed medication list – medication compliance is good.

Glucose records reviewed

Blood glucose monitoring is done 0-1 times daily.

The patient denies hypoglycemia or hypoglycemic symptoms, i.e. no dizziness, sweating, confusion or headaches.

Diet / Exercise / Weight:

Patient is overweight but generally follows a healthy diet. Goes to gym two to three times per week.

Diabetic Related Complications:

Neuropathy symptoms: Positive stocking/glove numbness or tingling. No mononeuropathy. No postprandial bloating.

Retinopathy: Up-to-date on routine surveillance. First diagnosed 1/22/2018.

Nephropathy: Positive. Up-to-date on routine surveillance.

Review of Systems

Constitutional/Endocrine/Musculoskeletal: Negative.

Social History

Smoking status: Does not smoke.

Physical Exam

BP: 140/82

Pulse: 78

Weight: 271 lb 12.8 oz (123.3 kg)

BMI: Body mass index is 36.86 kg/m²

General: Alert; NAD with normal affect.

Eyes: EOMI; no icterus.

HENT: Atraumatic; oropharynx clear with moist mucous membranes.

Neck: supple, normal size thyroid, no palpable nodules.

Respiratory: Normal respiratory effort.

Cardiovascular: Regular rate & rhythm; no edema.

Musculoskeletal: FROM; no synovitis.

Neurological: reflexes 2+ at biceps, relaxation phase normal; no tremor.

Skin: No rash; no ulcerations.

Diabetic Foot Exam: No Lesions; good pulses.

Assessment

Type 2 diabetes mellitus with hyperglycemia, with long-term current use of insulin

Type 2 diabetes mellitus with polyneuropathy

Type 2 diabetes mellitus with microalbuminuria, with long-term current use of insulin

Type 2 diabetes, uncontrolled, with retinopathy

Class 2 severe obesity due to excess calories with serious comorbidity and body mass index (BMI) of 36.0 to 36.9 in adult

Hyperlipidemia associated with type 2 diabetes mellitus

Hypertension associated with diabetes

Vitamin D deficiency

Documentation Coding Requirements

When documenting diabetes, include the following:

Type:

Type 1

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

Diagnosis Codes

E11.65 Type 2 diabetes mellitus with hyperglycemia

E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy

E11.29 Type 2 diabetes mellitus with other diabetic kidney complication

E11.319 Type 2 diabetes with unspecified diabetic retinopathy with macular edema

E11.69 Type 2 diabetes mellitus with other specified complication

E11.59 Type 2 diabetes mellitus with other circulatory complications

E66.01 Morbid (severe) obesity due to excess calories

Z68.36 Body mass index (BMI) 36.0-36.9, adult

Z79.4 Long term (current) use of insulin

E55.9 Vitamin D deficiency, unspecified

R80.9 Proteinuria, unspecified

E78.5 Hyperlipidemia, unspecified

Renee Dowling is a compliance auditor at Sansum Clinic, LLC, in Santa Barbara, California.