Wiki Long Standing Diabetes and Hypertension Audit Flag - Need Help!!!!!

[tgenius1]

An established patient presents to his doctor’s office for evaluation of long-standing diabetes and hypertension, currently doing well per patient. A detailed history was obtained and a detailed exam
was performed. Medical decision making was of moderate complexity. The patient requested evaluation of AK’s and SK’s. Following examination, patient agreed to have them removed. Two
AK’s were treated with Liquid Nitrogen and 2 SK’s were treated with Liquid Nitrogen. Assign the ICD-10-CM diagnosis & CPT procedure codes including modifiers, as appropriate

I coded 99214-25, 17000, 17003, L57.0, L82.1, I10 and E11.8. Auditor asked for me to recheck E11.8 for the long-standing diabetes. any recommendations on how long standing diabetes should be coded?

 

[mitchellde]

Why did you choose E11.8? If there is no documented complication then you would not code for one, just code for no complication.

 

[tgenius1]

Good Morning,

The reason I chose E11.8 is because of the coding guidelines and the fact the patient has hypertension (not really knowing did the patient have the hypertension prior to diabetes or vice versa). E11.8 is for Type 2 diabetes with unspecified complications being the hypertension. However, the auditor is saying that it's wrong. However, I looked at E11.9 and now I get it! make since I agree with you totally. thanks for helping me crack this code.

 

[CodingKing]

Correct E11.9 since Diabetes with Hypertension isn't a with option in the index thus connection needs to be established by the physician.