I35.0 - Nonrheumatic aortic (valve) stenosis

Clinical Definition

Diabetic retinopathy is a diabetes complication that affects the blood vessels in the retina, potentially leading to vision loss. The damage occurs when high blood sugar levels harm the delicate blood vessels of the retina.

Documentation Requirements

• Must specify type of diabetes (Type 1 or Type 2)

• Must document "with retinopathy"

• Must indicate:

  • Laterality (right eye, left eye, or bilateral)

  • Stage/severity (mild, moderate, severe, or proliferative)

  • With or without macular edema

  • Controlled vs uncontrolled diabetes

• Any associated vision loss or blindness

• Current A1C levels when available

Common Synonyms

• Diabetic eye disease

• Sugar eye problems

• Diabetes eye complications

• Eye damage from diabetes

• DR (medical abbreviation)

Coding Conflicts

Excludes1:

• Hypertensive retinopathy

• Background retinopathy not due to diabetes

• Retinal vein occlusion

Scribing.io Automation

The AI scribe automatically:

1. Identifies mentions of retinal changes in diabetic patients

2. Tags keywords like "proliferative," "non-proliferative," "macular edema"

3. Maps eye exam findings to severity levels

4. Links diabetes control status with retinopathy documentation

5. Flags missing elements (laterality, severity, etc.) for physician review

Note: Always verify correct diabetes type and current status is documented to ensure accurate code assignment.