Z12.11 - Encounter for screening for malignant neoplasm of colon

Clinical Definition

Type 2 diabetes mellitus is a chronic metabolic disorder characterized by insulin resistance and relative insulin deficiency, leading to elevated blood glucose levels. Unlike Type 1 diabetes, the pancreas still produces insulin but the body does not use it effectively.

Documentation Requirements

• Must specify "Type 2" diabetes (not just "diabetes mellitus")

• Document control status:

  • "With" or "Without" complications

  • "Controlled" or "Uncontrolled"

• Any associated manifestations must be linked with terms like:

  • "Due to"

  • "Associated with"

  • "With diabetic"

• Current A1C level if available

• Treatment regimen (oral medications, insulin, lifestyle modifications)

Common Synonyms

• Adult-onset diabetes

• Non-insulin dependent diabetes (NIDDM)

• Sugar diabetes

• High blood sugar

• "The sugar"

Coding Conflicts

Excludes1:

• Type 1 diabetes mellitus (E10.-)

• Neonatal diabetes mellitus (P70.2)

• Gestational diabetes (O24.4-)

Excludes2:

• Drug-induced diabetes mellitus (E09.-)

• Secondary diabetes mellitus (E08.-)

Scribing.io Automation

The AI scribe automatically:

• Recognizes variations of "Type 2 diabetes" and standardizes terminology

• Links complications using proper causal language

• Flags missing control status documentation

• Automatically associates A1C values when mentioned

• Highlights any documentation gaps needed for complete coding