StewartReneeLv7

26 Feb 2022

Help!! I’m trying to find the code for diabetes type 1. I know that the primary diagnosis is Hyperglycemia and the code for that is R73.9.

I also know that the secondary diagnosis is Type 1 Diabetes. I just can’t figure out if the correct code is E10.9 or if it’s E10.69

This is due today. Any help would be so much appreciated.

Quincy presents today for a follow-up for his Type I diabetes. He has had DMI for about 5 years now and is accompanied by his mother and father who provided the history.

Quincy's mother reported that his interval history is notable for problems such as widely fluctuating blood glucose levels, despite stable insulin doses, diet and life style.

 

Review of blood glucose log: Parents' check Quincy's blood glucose every night because they feel that he has hypoglycemia unawareness. With one exception, his blood glucose at night is always above 150mgdi. His first morning blood glucose has been in excess of 200 mg/di for the past month. Mom increased his Levemir dose to 5 units at bedtime. He appears to be at target or below around early afternoon and before dinner.

 

Review of Systems:

Constitutional: no fatigue, inappropriate weight gain, weight loss

Head: No headaches

Eyes: No vision concerns

Respiratory: No cough, chest pain

Abdominal: No pain, diarrhea, constipation Genitourinary: No polyuria, nocturia, no nocturnal enuresis Neurologic: No decreased sensation in hands or feet.

Musculoskeletal: No pain in feet, ingrown toenails Skin: No dry skin, injection or pump site problems Psychological: No social, emotional or coping concerns

 

Endocrine: No polydypsia, hypoglycemia unawareness

Other concerns: He complains of generally not feeling well even when his blood glucose is within expected range.

Past Medical History: DMII

Vitals: BP-120/58, Pulse-80, Ht-61.5", Wt-105lbs, BMI-19.8

Physical Examination General: alert and no distress

Head: normocephalic, atraumatic

Eyes: sclerae white, pupils equal and reactive

Ears: normal bilaterally

Nose: nares patent with no flaring and no discharge, swelling or lesions noted

Mouth: no abnormalities and mucous membranes moist, no oral lesions

Neck: supple with no lymphadenopathy, thyromegaly, or masses

Lungs: clear to auscultation bilaterally

Heart: regular rate and rhythm, no murmur

Abdomen: soft, nontender, bowel sounds present

Extremities: warm and dry, without abnormalities; fingertips appear healthy

Thyroid: thyroid is normal in size without nodules or tenderness

Tone: normal tone, bulk, and strength

Skin: normal and dry

Neurological: Alert and oriented; no focal abnormalities

Feet: Normal exam.