Primary Care Coding Alert

Question: What is the correct way to document type 2 diabetes with microalbuminuria? Would I use a combination code such as E11.69, or use an E11.- code with R80.9?

Nevada Subscriber

Answer: In this case, using an E11.- (Type 2 diabetes mellitus) code with R80.9 (Proteinuria, unspecified) would be unnecessary as a combination code for the two conditions exists, which you correctly suggest. However, though E11.69 (Type 2 diabetes mellitus with other specified complication) would seem to be a logical choice for type 2 diabetes with a specified complication such as microalbuminuria, in this instance, this diagnosis code would also be incorrect.

To understand why, consider the etiology for microalbuminuria. The condition, which is very often linked to type 2, occurs when small amounts of the protein albumin leak into the urine from the kidneys. Given its association with the kidneys, then, when the condition occurs with type 2, the combination code E11.29 (Type 2 diabetes mellitus with other diabetic kidney complication) would be more accurate.