ICD 10 Coding Alert

Reader Questions:

Don’t Forget Laterality When Reporting This Dx

Question: I’m having a little trouble with the abbreviations on an encounter note. What ICD-10-CM code should I select when encounter notes indicate that a patient suffers from “type 2 DM w/mild, nonprolif. Retinopathy + mac edema”

New Hampshire Subscriber

Answer: The ICD-10 for the condition that is shorthanded into the notes is E11.321- (Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema).

Don’t stop there: There are instructions to report this code to the 7th character to indicate laterality; use one of the following characters to fill out the ICD-10 code:

  • 1 = right eye
  • 2 = left eye
  • 3 = bilateral
  • 9 = unspecified eye.