Example #1
Provider’s documentation states:
DM without complications
Hypertension with CKD III
Coding:
E11.9, I12.9, N18.3
or we should code:
E11.22, I12.9, N18.3
Example #2
Provider’s documentation states:
DM
Hypertension with CKD III
Coding:
E11.22, I12.9, N18.3
Coded as guidelines stating.
Example #3
Provider’s documentation states:
DM without complications
Polyneuropathy
Coding:
E11.42
or we should code:
E11.9, G62.9
Example #4
Provider’s documentation states:
DM
Polyneuropathy
Coding:
E11.42
Coded as guideline stating.
Guidelines:
ICD10-CM presumes cause and effect linkage between DM and certain conditions unless the physician specifically indicates the conditions are not related. Conditions that appear in the index as indented subterms under the various types of "diabetes, with" are coded as diabetic complications, even in the absence of the physician documentation explicitly linking them, unless the documentation clearly indicates these conditions are not caused by diabetes for example, by stating:
Actual nondiabetes related cause
Cause is not diabetes
Diabetes is without complications
Cause is unknown.
Any help is much appreciated.
Thank you.