Z23 - Encounter for immunization

Clinical Definition

Diabetic retinopathy refers to damage of blood vessels in the retina specifically caused by diabetes mellitus. This vascular damage leads to impaired vision or potential blindness if left untreated.

Documentation Requirements

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

• Must document "diabetic retinopathy" specifically

• Must indicate laterality:

  • Right eye

  • Left eye

  • Bilateral

• Must specify severity:

  • Background/mild nonproliferative

  • Moderate nonproliferative

  • Severe nonproliferative

  • Proliferative

• Include presence/absence of macular edema

• Document current diabetes control status (controlled/uncontrolled)

Common Synonyms

• "Sugar eye disease"

• "Diabetic eye disease"

• "Diabetes eye complications"

• "Retinal damage from diabetes"

Coding Conflicts

Excludes1:

• Hypertensive retinopathy

• Non-diabetic retinopathy
  Excludes2:

• Glaucoma associated with diabetes

Scribing.io Automation

The AI scribe automatically:

• Flags mentions of vision changes in diabetic patients

• Identifies key terms like "proliferative" and "nonproliferative"

• Links eye exam findings with diabetes diagnosis

• Maps laterality based on context

• Highlights severity indicators

• Cross-references with current diabetes control documentation

Reference ICD-10 codes: E11.3- (Type 2) or E10.3- (Type 1) series with appropriate additional digits for specificity.