BOX 1. Case Studies for Diabetes Coding

Case 1:
The patient is a 45-year-old man who has had type 1 diabetes for 25 years. At today’s visit, he is diagnosed with gastroparesis. He reports one hypoglycemic episode with a random glucose of 43 mg/dL. His A1C is 7.4%. The patient has a history of nonproliferative retinopathy and CKD stage 1. You provide dietary counseling during the visit. What codes would you use?
Answer:
  • E10.65: Type 1 diabetes with hyperlgycemia

  • E10.43: Type 1 diabetes with gastroparesis (autonomic neuropathy)

  • E10.329: Type 1 diabetes with nonproliferative retinopathy

  • E10.649: Type 1 diabetes with hypoglycemia

  • E10.22: Type 1 diabetes with CKD stage 1

  • K31.84: Gastroparesis

  • Z71.3: Dietary counseling

  • Z79.4: Insulin use

Case 2:
The patient is a 53-year-old obese man (BMI 37 kg/m2) who has uncontrolled type 2 diabetes with A1C of 8.8%, CKD stage 3, controlled hypertension on an ACE inhibitor, and mixed hyperlipidemia. He takes daily insulin injections. What codes would you use?
Answer:
  • E11.65: Type 2 diabetes with hyperglycemia

  • E11.22: Type 2 diabetes with CKD

  • N18.3: CKD stage 3

  • E78.2: Mixed hyperlipidemia

  • I10: Essential hypertension

  • Z79.4: Insulin use

  • Z68.37: Obesity