Wiki How to Code long standing diabetes and hypertension

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tgenius1

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patient presents to office for evaluation of long standing diabetes and hypertension. coder coded I10 and E11.8 (auditor asked to recheck E11.8) any help?
 
What do you think about the Type 2 diabetes mellitus with unspecified complication?

You may want to review ICD-10-CM guideline I.A.15 to see if it might apply here.
 
Good Morning,

I check the coding guidelines and it referenced coding the E11 however I coded E11.8 which does state type 2 diabetes mellitus with unspecified complications but the auditor is stating that's wrong. I will submit my rational and reference the coding guidelines.

Thanks a million.
 
Long standing diabetes is not in and of itself a complication. unless there is a complication documented or hypertension listed under the word "with" in the alpha listing then there is no reason for coding diabetes with an unspecified complication. I am curious as to why you feel this is an appropriate selection.
 
Hello,

I did recode the dx to E11.9 and it was right. you are the best!!!! Thanks for your help. I am going to be sending two more your way in just a second if you can help me out that would be great!
 
Patient presents for anemia. Dietician documents BMI of 35.6. Patient is treated with iron for the anemia. I coded it D64.9 and Z68.35 but I was cited by the auditor. The first time I was cited for coding it with just the D50.9.

However, I did look at D50.9 and Z68.35 any thoughts?
 
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This other one is really confusing me because I was cited twice

Patient is 62 years old referred to Physical Therapy with a diagnosis of low back pain and left ankle pain 15 minutes of Therapeutic Exercises
15 minutes of Heat/Cold Therapy
Return to Clinic in 1 week
Performed by a Physical Therapist

I coded M54.5 for the back pain and was cited incorrect then I re-coded to R52 and was cited incorrect again. I am totally confused any thoughts?
 
tgenius1 said:
Patient presents for anemia. Dietician documents BMI of 35.6. Patient is treated with iron for the anemia. I coded it D64.9 and Z68.35 but I was cited by the auditor. The first time I was cited for coding it with just the D50.9.

However, I did look at D50.9 and Z68.35 any thoughts?
Click to expand...

D64.9 is correct for unspecified anemia - perhaps the auditor felt that Z68.35 should not have been coded in addition since there is no 'code also' note for BMI under the anemia, or perhaps because it was documented by the dietician and not the physician?
 
tgenius1 said:
This other one is really confusing me because I was cited twice

Patient is 62 years old referred to Physical Therapy with a diagnosis of low back pain and left ankle pain 15 minutes of Therapeutic Exercises
15 minutes of Heat/Cold Therapy
Return to Clinic in 1 week
Performed by a Physical Therapist

I coded M54.5 for the back pain and was cited incorrect then I re-coded to R52 and was cited incorrect again. I am totally confused any thoughts?
Click to expand...

M54.5 is correct for low back pain, plus M25.572 for left ankle pain.
 
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