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Austin Regional Clinic ICD-10-CM Documentation Quick Reference Guide Diabetes Mellitus ICD-9 CODE ICD-9 DESCRIPTION ICD-10 CODE More specific ICD-10 options include: Not a complete list 250.00 Diabetes mellitus (DM) without mention of complication, type II or unspecified type, not stated as uncontrolled ICD-10 DESCRIPTION E10.9 Type 1 diabetes mellitus w/o complications E11.9 Type 2 diabetes mellitus w/o complications E13.9 Other specified diabetes mellitus w/o complications O24.419 Gestational diabetes mellitus in pregnancy, unspec control E10.621 Type 1 DM with foot ulcer E10.52 Type 1 DM with peripheral angiopathy with gangrene E11.12 Type 2 DM with diabetic nephropathy E11.22 Type 2 DM with diabetic CKD E11.610 Type 2 DM with diabetic neuropathic arthropathy (Charcot’s joint) DOCUMENTATION CONCEPTS Type: Type 1 (E10.9) Type 2 (E11.9) Secondary DM (with type 1 or 2) Underlying etiology (i.e. chemical or drug-induced, autoimmune, etc.) Associated complications: Gestational diabetes Diabetic foot ulcer Diabetic nephropathy / diabetic CKD Diabetic peripheral angiopathy Diabetic autonomic neuropathy Charcot’s joint(s) Diabetic osteomyelitis (Relationship is no longer presumed; Need to link the two conditions, if appropriate) Acuity (acute, subacute, chronic) Location (ankle, foot, vertebra, etc.) Laterality (right, left, bilateral) Infectious agent With gangrene With hyperglycemia Control status (No longer “controlled or uncontrolled”) Out of control Poorly controlled Insulin use: Long-term (current) insulin (Z79.4) Underdosing or overdosing related to insulin pump malfunction Intentional, unintentional Reason (financial, dementia, etc. Austin Regional Clinic ICD-10-CM Documentation Quick Reference Guide Diabetes Mellitus ICD-9 DESCRIPTION ICD-10 DESCRIPTION INAPPROPRIATE DOCUMENTATION EXAMPLE APPROPRIATE DOCUMENTATION EXAMPLE Diagnosis: 250.00 Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled HPI: Diabetes - eating sweets. Sugars 132 and 117. Taking medications regularly. Exercising regularly. Assessment/Plan: Unspecified Diabetes Mellitus Chronic kidney disease (CKD) - continue current medications Concept(s) requirement not met: no type indicated, control status not documented, no relationship link to complications, no plan of care Diagnosis: E11.22 Type 2 Diabetes Mellitus with diabetic CKD HPI: This patient is seen today with numerous medical problems that include OSA on CPAP, DM II, Obesity, Hypothyroidism, CKD due to DM and Hyperlipidemia who presents highly spirited for re-evaluation. + FHX of DM. He was last seen 3 months ago, at which point labs showed GFR 46, glucose 160, HgbA1c of 7.2. Assessment/Plan: Diabetes Mellitus, Type 2, poorly controlled Diabetic nephropathy with CKD Stage III - Metabolic, Comprehensive - Hemoglobin A1C-HPLC; Future - CBC W/Diff (auto); Future - sitaGLIPtin (JANUVIA) 100 MG PO tablet; Take 1 tablet (100 mg total) by mouth daily Concept(s) requirement not met: no type indicated, control status not documented, no relationship link to complications, no plan of care