Wiki Diabetes with Manifestations NOT linked

[princesskass16]

I have a electronic record from a podiatrist that says:
Reason for appointment
1. Long thickened nails and callus tissue which are painful with ambulation and in shoegear
2. IDDM

Current Medications
Albuterol
ASA-APAP-Salicyl-Caff
Prinivil
Toprol
Fosamax
Insulin Regular Human
Medication list reviewed with patient

PMH
IDDM
HTN
Asthma

HPI
FBS 114. No other changes noted.

Exam
Skin bilaterally: cool, dry, shiny atrophic skin no hair growth. Negative cyanosis, clubbing nor open lesions. 1+ edema with pitting to the mid tibia. Painful callus tissue medial fifth right and lateral PIPJ fourth right.
Nails: long, brittle, dystrophic, 5 bilaterally remainder long
Vascular: 2+/4+ DP, 2+/4+ PT right; 0/4+ DP, 0/4+ PT left. CFT<4 sec x 10.
Neuro: Intact to light touch & proprioception. NPR bil. Negative clonus/ Achilles reflex 0/4+ bil. Intact to vibratory & plantar sharp/dull sensation bil.
Biomechanical: Laterally deviated hallux bil. Dorsally contracted digits 2-5 bil. Decreased long arch height. Overlapping toes 5 under 4 bil.

Assessments
1. Diabetes with neurological manifestations, Type II or unspecified type - 250.60
2. Acquired keratoderma - 701.1
3. Onychauxis - 703.8
4. Lesion, soft tissue - 216.7
5. Diabetes mellitus without mention of complication, type II or unspecified - 250.00
6. Pain in soft tissues of limb - 729.5
7. Edema 782.3
8. Diabetes with peripheral circulatory disorders, type II - 250.70

1. IDDM with foot pain secondary to onychauxis and painful hyperkeratotic tissue
2. PVD, pedal edema, neuropathy, no pedal pulses left, hallux valgus, hammertoes, overlapping toes

Treatment
1. Diabetes with neurological manifestations, type II or unspecified type
Continue Insulin Regular Human
Notes: Diabetic footcare
2. Acquired keratoderma
Notes: Reduce and debride painful callus tissue
3. Onychauxis
Notes: debride and reduce nails


So from this, would you automatically link the neuropathy mentioned to the "diabetes with neurological manifestations" and the PVD to the "diabetes with circulatory manifestations" based on where they are mentioned in the chart?

Or would you code diabetes without manifestation, neuropathy, and PVD separately?

So which is the right answer, for the diabetes portion?:
A) 250.60, 357.2, 250.70, 443.81
B) 250.00, 355.9, 443.9
C) 250.60, 250.70, 250.00, 443.9, 355.9

Thanks!

 

[mitchellde]

You never code the 250.00 with any other codes that indicate complication so answer C is incorrect. Honestly I would not code from this at all it is way too contradictory . I would need to see the note of the encounter.

 

[BenCrocker]

Looks like a very loose connection for the Diabetic Foot Care in Treatment 1. Other than that it's hard to accurately code this without the whole note.

 

[princesskass16]

I have updated the post so it shows the whole note

 

[mitchellde]

The exam does not describe nor address the presence of any diabetic complications. It is very poorly written. There are several diagnosis in the assume that that are not addressed and some are contrary to the exam. I do not see how you can support any diabetic complication with this note. I see the nail issue and the insulin dependent diabetes ( don't forget the V58.67), the callus is mentioned, he gives a vascular assessment but does not tie that into a dx of PVD or a complication. The provider cannot give a simple exam and then in the assessment pull diagnosis out of thin air. I would be inclined to code the 250.00 for the diabetes with the painful toenails.

 

[BenCrocker]

I second Debras message. It's too unclear, and there are way too many loose associations.