Type 2 Diabetes Mellitus Documentation Guide
Metabolic disorder characterized by insulin resistance and elevated blood glucose.
ICD-10 Codes: E11.9, E11.65, E11.21, E11.22, E11.29, E11.40, E11.42, E11.51, E11.52
Common Symptoms
- Polyuria
- Polydipsia
- Fatigue
- Blurred vision
- Slow wound healing
Key Documentation Elements
- Current A1C and trend
- Diabetes medications with doses
- Complications screening (eyes, feet, kidneys)
- Hypoglycemia assessment
- Lifestyle modification counseling
Documentation Challenges
- Capturing all diabetes complications
- Documenting A1C trends and goals
- Recording medication adjustments
- Tracking diabetes education provided
Billing Considerations
- Comprehensive HCC capture for complications
- Proper specificity (with/without complications)
- Chronic care management opportunities
- Diabetes self-management education billing
Frequently Asked Questions
How do I capture all diabetes complications?
Scribeable prompts you to document common complications (nephropathy, retinopathy, neuropathy) and automatically applies the correct E11.x codes for each documented complication.
What HCC codes are relevant for diabetes?
Diabetes with complications (E11.2x-E11.6x) are HCC conditions. Scribeable helps capture these for accurate risk adjustment and reimbursement.