Case Study Example for ICD-10-CM
Here is an example of an ICD-10-CM case study that will help you understand proper coding.
CHIEF COMPLAINT: Follow up on Diabetes.
HISTORY OF PRESENT ILLNESS:
- Established female patient presents today for a re-evaluation of her Diabetes Mellitus Type I.
- Last A1C was done in April with a result of 7.8.
- Patient is doing Accuchecks on a regular basis. Patient is being following a strict diet.
- Patient is taking medications as prescribed and also is having problems with neuropathy.
- The onset was 2 week ago. Status has been worse, gradually. She states it is a burning in her feet.
REVIEW OF SYSTEMS: MUSCULOSKELETAL:
- Negative for, rheumatologic manifestations, back pain, myalgia.
- Positive for burning in her feet.
DIABETIC: Negative for:
- Polyuria
- Polydipsia
- Hypoglycemia
- New infection
- Weight loss
- Weight gain
- Paresthesia
- Chest pain
- Shortness of breath
- Dyspnea on exertion
- Claudication symptoms,
- New neurological symptoms
- Post prandial bloating
- Orthostasis
- Leg cramps
- Vision changes.
MEDICATIONS:
Humulin R, 100U/ml, 45 units AC.
Lantus 100U/ml, 60 units HS.
Exam: WNL
ASSESSMENT/PLAN:
1) Diabetes Type I) Diabetic Neuralgia. Medications were reviewed with the patient. Poor control-Medications were reviewed with the patient. Clinical lab work was done today. Continue present management. The patient was instructed on 1600 cal ADA diet.
Coding :
Diabetes is documented as Type I. A combination code is used for Type I Diabetes with Neuropathy. The look-up of Diabetes, Type I, with neuralgia leads to E10.42 Type I Diabetes Mellitus with diabetic polyneuropathy. Because the patient is Type I the guidelines state the code for long-term use of insulin is not reported.