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Monthly CDI Scenario Discussion – October 2020

Topic:  Diabetes

Scenario: 68 yr. F presents with nausea/vomiting and upper abdominal pain for 7 days with PMH of Diabetes

H&P: Pt. arrived to ED with complaints of nausea and vomiting with upper abdominal pain for 7 days. ABD CT negative for any acute pathology. PHM of type 2 diabetes, neuropathy, hypothyroidism, and SBO.  She has home medications of levothyroxine, glucovance, ondansetron, and gabapentin.  The H&P notes: “patient relates that she has had unintentional weight loss as she has not been interested in eating because it just comes back up later.”  We will admit for n/v and abdominal pain. Plan to consult GI

Day 1 Progress Note: Patient appears to be failing to thrive, nutrition consult is ordered, BS is 575-uncontrolled diabetes.

GI Consult: 68 yr. old with complaints of nausea and vomiting with upper abdominal pain. Films negative. PMH of DM2 will plan to order gastric motility study.

GI Consult Progress Note: Gastric motilitystudy suggestive of mild delay, suspect this is related to her diabetes. Pt. counseled on dietary changes and Reglan started.

Day 2 Progress Notes: Seen by GI, n/v/Abd pain though to be related to gastroparesis. Started on Reglan. Will monitor trial of Reglan. Dietary to see patient later today.

Dietitian Consult Note: < 50% estimated energy intake compared to estimated energy needs for ≥ 1-month, unintentional weight loss of > 5% in 1 month with notable severe clavicular and shoulder muscle depletion with recommendation for supplemental nutrition.

Discharge Summary: Nausea, vomiting, and upper abdominal pain resolved. Thought to be related to gastroparesis. Continue Reglan on discharge, Rx given, and follow-up with GI in 1-2 weeks. Pt. also instructed to continue Ensure at least twice daily and follow up with PCP.

Question: Are there query opportunities based on the scenario stated above?


Alphabetic Index lists the following code titles:

  • Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy (E11.43)
  • Gastroparesis (K31.84)

Consider the coding guideline “with” and pertinent Coding Clinic Advice (included in CDI Educational Tips) when considering the principal diagnosis.

Patient presented with indicators of malnutrition. This was further confirmed by the documentation by the dietitian which meets the ASPEN criteria for severe malnutrition in the context of chronic illness.

Patient demonstrated a high blood glucose with PMH of DM2 with ‘uncontrolled diabetes’ documented.

UASI Recommendation:

  • Query for Severe Protein Calorie Malnutrition.
  • Query for DM with Hyperglycemia.

Documentation without Clarification:

  • Working Principal Diagnosis:  Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy (E11.43)
  • Working Secondary Diagnoses: Gastroparesis (K31.84), hypothyroidism unspecified (E03.9), Type 2 diabetes mellitus with diabetic neuropathy (E1140)
  • Working DRG: 074 – Cranial & peripheral nerve disorders w/o MCC 
  • RW: 0.9881         GMLOS: 2.9        SOI/ROM: 1/1

Documentation with Clarification:

  • Working Principal Diagnosis: Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy (E11.43)
  • Working Secondary diagnosis: Unspecified severe protein calorie malnutrition (E43), Type 2 diabetes mellitus with hyperglycemia (E1165), Gastroparesis (K31.84), hypothyroidism unspecified (E03.9), Type 2 diabetes mellitus with diabetic neuropathy (E1140)
  • Working DRG: DRG 073-Cranial & peripheral nerve disorders w/ MCC 
  • RW: 1.4156         GMLOS: 3.6        SOI/ROM:2/2

CDI Educational Tips: 

Official Coding Guideline I.A.15 titled (“with”): “The word ‘with’ or ‘in’ should be interpreted to mean ‘associated with’ or ‘due to’ when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.”

Patients with diabetes often develop conditions that affect various body systems due to the diabetes and these conditions are considered complications. If a complication is listed in the ICD-10 Alphabetic Index as Diabetes ‘with’, then the condition is assumed to be due to the diabetes and is reported as a diabetic complication, unless the provider clearly states the condition is unrelated to diabetes (or another guideline exists that specifically requires provider documentation to link the two conditions). For example, sepsis guidelines require that provider documentation clearly link organ failure to sepsis.

Poorly controlled, inadequately controlled, or out of control diabetes is reported as diabetes with hyperglycemia. “Uncontrolled” diabetes requires clarification as diabetes with hyperglycemia or hypoglycemia.

Common complications that are presumed to be due to diabetes include:

  • Cataract
  • Charcot’s joint
  • CKD
  • Gangrene
  • Gastroparesis
  • Glaucoma
  • Nephropathy
  • Neuralgia
  • Neuropathy
  • Osteomyelitis
  • Peripheral Angiopathy
  • Retinopathy
  • Foot Ulcer
  • Skin Ulcer

This is a short synopsis of a possible patient record and is not intended to be all inclusive.  This is for educational purposes only and not intended to replace your institutional guidelines.