What ICD-10-CM code should be assigned for diabetic ketoacidosis (DKA), if the type of diabetes isn’t documented or specified by the physician? The ICD-10-CM Official Guidelines state that if the type of diabetes mellitus is not documented in the medical record, the default is a code from subcategory E11.-, Type 2 Diabetes mellitus.
The index advises coders to code “diabetes, by type, with ketoacidosis” when referencing ketoacidosis. Therefore, query the physician for clarification regarding the type of diabetes when diabetic ketoacidosis is documented without further specification of type.
Diabetic ketoacidosis (DKA) is an acute, life threatening complication of diabetes that mainly occurs in patients with type 1 diabetes, but can occur in patients with type 2 diabetes. As previously stated in Coding Clinic First Quarter 2013, pages 26-27, code E13.10, Other specified diabetes mellitus with ketoacidosis without coma, is assigned for type 2 diabetic ketoacidosis since the condition does not currently have a specific code in ICD-10-CM.