Clinical documentation and uhdds guidelines

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Reference no: EM133329619

Case - Patient Name: Mario Fugo

The patient is a 51-year-old male who is a type 1 insulin-dependent diabetic. He was admitted to UCLA medical center per physician documentation for the treatment of a grade III foot ulcer which involved necrosis of the muscle on the left foot with gangrenous changes resulting from diabetic neuropathy, atherosclerosis, and chronic peripheral vascular insufficiency. Excisional debridement of the ulcer to the muscle was done during this hospital admission. After 5 days in the hospital the patient was discharged to rehab in good condition.

Codes assigned are:
Principal diagnosis: E10.69
Additional diagnoses: I70.202, I96, G62.9, L97.523
Procedure codes assigned: 0JDR0ZZ

Question: Are these the correct codes per the clinical documentation and ICD-10-CM/PCS coding guidelines? Is E10.69 the correct principal diagnosis per the clinical documentation and UHDDS guidelines?

Reference no: EM133329619

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