Revenue Cycle Insider

Question: I have a report from an encounter with a patient with type 2 diabetes mellitus. The patient takes insulin for their diabetes, and the report indicates the patient has a non-pressure chronic ulcer of the midfoot with the fat layer exposed.

How do I report the diagnosis?

Vermont Subscriber

Answer: Use E11.621 (Type 2 diabetes mellitus with foot ulcer) to report the type 2 diabetes mellitus and foot ulcer. This code has a note instructing you to use an additional code to identify where the ulcer is located. Assign L97.412 (Non-pressure chronic ulcer of right heel and midfoot with fat layer exposed) to indicate the patient’s non-pressure chronic ulcer of the midfoot with the fat layer exposed.

You also need to identify how the patient’s type 2 diabetes mellitus is being controlled. Parent code E11.- (Type 2 diabetes mellitus) features a Use additional code note instructing you to use an appropriate code for the following treatments:

• Injectable non-insulin antidiabetic drugs
• Insulin
• Oral antidiabetic drugs
• Oral hypoglycemic drugs

Since the patient uses insulin to control their diabetes mellitus, assign Z79.4 (Long term (current) use of insulin) to the claim.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC