Reader Question: You Can Assume Type I With Ketoacidosis

Question: If our endocrinologist documents a patient with diabetic ketoacidosis but does not specify whether the patient is Type I or Type II, how should we code?

Colorado Subscriber

Answer: Diabetic ketoacidosis is almost exclusively found in Type I diabetics. Therefore, as long as your endocrinologist documents diabetic ketoacidosis (be sure that the diabetes is the cause of the acute condition), you can assume that the patient has Type I diabetes. This limits your fifth-digit choices to 1 or 3.
 
The only exception to this is if the endocrinologist specifies in the documentation that the patient is a Type II diabetic. As for determining whether the diabetes is controlled or uncontrolled, you may need to ask your physician. Diabetic ketoacidosis is a condition characterized by excessively high and uncontrolled glucose levels. The very fact that a patient has ketoacidosis may indicate that the patient's diabetes is uncontrolled, but you should check with the endocrinologist.