Find information on Type 2 Diabetes Mellitus with Foot Ulcer diagnosis, including clinical documentation, medical coding, ICD-10 codes E11.65 and L97.409, diabetic foot care, wound care, ulcer management, peripheral neuropathy, and vascular disease. Learn about healthcare guidelines, treatment options, and best practices for accurate reporting and improved patient outcomes related to diabetic foot ulcers and Type 2 Diabetes Mellitus complications.
Also known as
Type 2 DM with foot ulcer
Type 2 diabetes mellitus with foot ulcer.
Type 2 DM with peripheral angiopathy
Type 2 diabetes with circulatory issues in the limbs.
Non-pressure ulcers of lower limb
Ulcers on the legs and feet not caused by pressure.
Atherosclerosis
Hardening and narrowing of the arteries.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the ulcer documented as diabetic?
Yes
Is there gangrene?
No
Do NOT code as a diabetic ulcer. Code diabetes (E11.-) and ulcer (L97.-) with appropriate site and non-diabetic etiology.
When to use each related code
| Description |
|---|
| Diabetes with foot ulcer |
| Diabetic peripheral neuropathy |
| Peripheral artery disease |
Coding requires specifying if the ulcer is diabetic, arterial, or venous. Unspecified etiology leads to inaccurate coding and reimbursement.
Failing to document ulcer location (right/left) and stage (severity) impacts coding specificity, affecting quality metrics and payment.
Presence or absence of infection significantly alters coding. Missing infection documentation impacts severity reflection and appropriate care planning.
Patient presents with Type 2 diabetes mellitus complicated by a diabetic foot ulcer. The patient reports a history of poorly controlled blood glucose levels and peripheral neuropathy. On physical examination, a neuropathic ulcer is observed on the plantar surface of the right foot, measuring approximately 2 cm x 3 cm. The ulcer base appears pale with moderate exudate. Surrounding skin exhibits signs of callus formation and decreased sensation to monofilament testing. Assessment includes diabetic foot exam, peripheral neuropathy assessment, and wound assessment. Diagnosis of Type 2 diabetes mellitus with foot ulcer is confirmed based on patient history, physical examination findings, and current hyperglycemia. Plan includes wound debridement, offloading with a total contact cast, and optimization of glycemic control through medication adjustment and diabetes self-management education. Patient education emphasizes the importance of regular foot inspections, proper footwear, and adherence to the prescribed treatment plan. Follow-up appointment scheduled in one week to monitor wound healing progress and adjust treatment as necessary. Differential diagnoses considered include infection, peripheral artery disease, and venous insufficiency. ICD-10 codes E11.65 and L97.421 are appropriate for this encounter. Focus on wound care management, infection prevention, and blood sugar control is crucial to prevent complications such as osteomyelitis and amputation.