Question

If a diabetic patient uses insulin, and the type of diabetes is not documented, what type of diabetes would be coded according to ICD-10-CM guidelines

Answer 1

The guidelines state that if the type of diabetes is not documented, the default is type 2.

The guidelines also instruct to use additional codes to identify long-term control with insulin (Z79. 4) or oral hypoglycemic drugs (Z79. 84).

The type of diabetes mellitus should always be clearly documented in the medical record for each date of service. However, if the type of diabetes mellitus is not documented in the medical record, the default ICD-10 diagnosis code is E11, type 2 diabetes mellitus.

Secondary diabetes can be defined as a diabetic condition that develops after the destruction of the beta-cells in the pancreatic islets and/or the induction of insulin resistance by an acquired disease (e.g. endocrinopathies) or others.

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