ICD-10 Coding Snapshot
Subjective: I am asked to see the patient today for ongoing issues around her diabetic control. We have been fairly aggressively, downwardly adjusting her insulins, both the Lantus insulin, which we had been giving at night, as well as her sliding scale Humalog insulin prior to meals. Despite frequent decreases in her insulin regimen, she continues to have somewhat low blood glucoses, most notably in the morning when the glucoses have been in the 70s despite decreasing her Lantus insulin from around 84 units down to 60 units, which is a considerable change. What I cannot explain is why her glucoses have not really climbed at all despite the decrease in insulin. The staff reports to me that her appetite is good and that she is eating as well as ever. She feels a little fatigued, but otherwise is doing well.
Physical Exam: Vitals are normal. The patient is pleasant and cooperative in no acute distress.
Assessment and Plan: Diabetes, still with hypoglycemia, most notably in the morning. To address the situation, I am going to hold her Lantus tonight and decrease then change the administration time to the morning. She will get 55 units in the morning. I am also decreasing her Humalog sliding scale prior to meals. I will review the blood glucoses again next week.
ICD-10-CM Code(s): E11.649 Type 2 diabetes mellitus with hypoglycemia without coma
Z79.4 Long-term (current) use of insulin
Rationale: According to the guidelines, when the type of diabetes is not documented, the type must be assumed to be type 2. Even if the main term Diabetes, with the subterm insulin dependent, is looked up, it indicates to code to type of diabetes. It is important for the provider to indicate the type to ensure proper coding of diabetes. Because this patient must be assumed to be a type 2 by default, a second code is necessary to indicate the insulin usage.