I25.110 - Atherosclerotic heart disease of native coronary artery with unstable angina pectoris

Clinical Definition

A metabolic disorder where the body resists insulin action or doesn't produce enough insulin, resulting in elevated blood glucose levels. Type 2 diabetes typically develops gradually with insulin resistance preceding the diagnosis.

Documentation Requirements

• Specify type of diabetes (Type 2)

• Document current A1C levels

• Note control status (controlled/uncontrolled)

• Document any complications:

  • Nephropathy

  • Retinopathy

  • Neuropathy

  • Vascular complications

• Specify if insulin-dependent

• Document any ketoacidosis episodes

• Indicate if diabetes is long-term (chronic)

• Link causal relationships between diabetes and complications using terms like "due to" or "diabetic"

Common Synonyms

• Adult-onset diabetes

• Sugar diabetes

• Non-insulin dependent diabetes (outdated)

• High blood sugar

• Hyperglycemia

Coding Conflicts

Excludes1:

• Type 1 diabetes mellitus

• Neonatal diabetes mellitus

• Gestational diabetes

• Drug-induced diabetes

Scribing.io Automation

The AI scribe automatically:

• Detects mentions of glucose levels and A1C values

• Identifies control status keywords

• Links complications to diabetes when mentioned in proximity

• Flags missing specificity for complications

• Captures insulin usage documentation

• Recognizes temporal language indicating chronicity

Remember to verbally confirm chronicity and control status during the encounter for accurate documentation.