What you need to know about coding a follow-up appointment for 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 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.
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 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
Smoking status: Does not smoke.
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.
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:
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
Left Right Bilateral
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.