We need clarification when coding from the following examples:
Example #1
Provider's documentation states:
DM without complications
Hypertension with CKD III
Coding:
E11.9, I12.9, N18.3
Can we coders assume and code E11.22 when provider stating the DM is without complications?
(E11.22, I12.9, N18.3)
Example #2
Provider's documentation states:
DM (Diabetes Mellitus)
Hypertension with CKD III
Coding:
E11.22, I12.9, N18.3
Coded as guidelines stating.
Example #3
Provider's documentation states:
DM without complications
Polyneuropathy
Coding:
E11.42
or we should code:
E11.9, G62.9
Example #4
Provider's documentation states:
DM (Diabetes Mellitus)
Polyneuropathy
Coding:
E11.42
Coded as guideline stating.
Example #5
Documentation Provider's states:
DM with Hypertension
DM with CAD (Coronary Artery Disease)
DM with Atherosclerosis of aorta
Can coders code E11.59?
Example #6
Provider's documentation states:
DM (Diabetes Mellitus)
Hyperlipidemia
Hypertension
Aherosclerosis of aorta
can coders assume and code E11.59 or E11.69?
Guidelines:
ICD10-CM presumes cause and effect linkage between DM and certain conditions unless the physician specifically indicates the conditions are not related. Conditions that appear in the index as indented subterms under the various types of "diabetes, with" are coded as diabetic complications, even in the absence of the physician documentation explicitly linking them, unless the documentation clearly indicates these conditions are not caused by diabetes for example, by stating:
Actual nondiabetes related cause
Cause is not diabetes
Diabetes is without complications
Cause is unknown.
Any help is much appreciated.
Thank you.
Example #1
Provider's documentation states:
DM without complications
Hypertension with CKD III
Coding:
E11.9, I12.9, N18.3
Can we coders assume and code E11.22 when provider stating the DM is without complications?
(E11.22, I12.9, N18.3)
Example #2
Provider's documentation states:
DM (Diabetes Mellitus)
Hypertension with CKD III
Coding:
E11.22, I12.9, N18.3
Coded as guidelines stating.
Example #3
Provider's documentation states:
DM without complications
Polyneuropathy
Coding:
E11.42
or we should code:
E11.9, G62.9
Example #4
Provider's documentation states:
DM (Diabetes Mellitus)
Polyneuropathy
Coding:
E11.42
Coded as guideline stating.
Example #5
Documentation Provider's states:
DM with Hypertension
DM with CAD (Coronary Artery Disease)
DM with Atherosclerosis of aorta
Can coders code E11.59?
Example #6
Provider's documentation states:
DM (Diabetes Mellitus)
Hyperlipidemia
Hypertension
Aherosclerosis of aorta
can coders assume and code E11.59 or E11.69?
Guidelines:
ICD10-CM presumes cause and effect linkage between DM and certain conditions unless the physician specifically indicates the conditions are not related. Conditions that appear in the index as indented subterms under the various types of "diabetes, with" are coded as diabetic complications, even in the absence of the physician documentation explicitly linking them, unless the documentation clearly indicates these conditions are not caused by diabetes for example, by stating:
Actual nondiabetes related cause
Cause is not diabetes
Diabetes is without complications
Cause is unknown.
Any help is much appreciated.
Thank you.
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