Internal Medicine Coding Alert

Question: A new patient with diabetes reports to the internist for an initial evaluation. The physician performs a level-three E/M and diagnoses the patient with ketoacidosis caused by his uncontrolled diabetes. However, the notes do not indicate whether the patient has type I or type II diabetes. How should I choose a diagnosis code?

Connecticut Subscriber

Answer: You should ask your physician just to be sure. Because ketoacidosis is found almost exclusively in type I patients, the patient likely has type I diabetes.

If the ketoacidosis is caused by the diabetes, you can be fairly certain that the patient has type I diabetes. The only exception might occur if the internist specifically notes that the patient is a type II diabetic.

Again, you should double-check to be sure, but you'll likely report the following on the claim:

• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; medical decision-making of low complexity) for the E/M

• 250.13 (Diabetes with ketoacidosis; type I [juvenile type], uncontrolled) linked to 99203 represent the patient's diabetic ketoacidosis.