MDS Alert

Question: I have a resident who is being admitted to our facility due to a urinary tract infection (UTI). However, the resident’s documentation suggests that the UTI is due to type 2 diabetes. How do I code this on the MDS? Which ICD-10 codes should I choose to correctly code for type 2 diabetes and a UTI? Should I use E11.69 or E11.29?

Delaware Subscriber

Answer: When coding Item I0020 on the MDS, you should choose 13, Medically Complex Conditions.

To choose an ICD-10 code, look to how the provider documented the resident’s condition. If the resident’s diabetes is the cause of the UTI, which is true for people whose diabetes is long term and poorly controlled, and who have developed complications such as renal papillary necrosis, cystopathy, or nephropathy as a consequence, then E11.69 (Type 2 diabetes mellitus with other specified complication) or E11.29 (Type 2 diabetes mellitus with other diabetic kidney complication) may be appropriate codes to use.

Should you go with E11.69, however, be aware of the “Use additional code to identify complication” note that goes with it. This means you would code the UTI as well using a code such as N39.0 (Urinary tract infection, site not specified), N10 (Acute pyelonephritis), N30.- (Cystitis), or N34.- (Urethritis and urethral syndrome).

However, should the provider document that the two conditions are not related, you’ll code the diabetes with E11.9 (Type 2 diabetes mellitus without complications) and an appropriate code for the UTI, assuming that the clinician addressed both conditions.