• Type (type 1, type 2 or secondary to another cause [drug, underlying condition]).
• Control status (inadequately controlled, poorly controlled, out of control).
• Episodes of hypo- or hyper-glycemia
• Insulin use (including insulin pump)
• Manifestations/Complications
  • Circulatory complications (e.g., peripheral . . .

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• Document location:
  • Portal vein
  • Hepatic vein
  • Vena cava, superior, inferior
  • Thoracic vein
  • Renal vein
  • Deep vein of lower extremity
  • Femoral vein
  • Iliac vein
  • Tibial vein
  • Superficial vessel of upper extremity
  • Deep vein of upper extremity
  • Antecubital vein
  • Basilic vein
  • Cephalic . . .

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Document site: Thigh, Calf, Ankle
Document if associated with: Ulcer, Inflammation, Edema, Swelling

Adult (main)|Pediatrics (main)

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• Be clear on your intended diagnosis. If known or suspected, document:
  • Vertebro-basilar artery syndrome
  • Carotid artery syndrome
  • Precerebral artery syndrome
  • Amaurosis fugax
  • Transient global amnesia
  • Other cerebral ischemia attacks and Syndromes
• Diagnosis of TIA = “unspecified” code

. . .

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• Link to underlying cause, examples:
  • COPD Exacerbation
  • Acute Respiratory Failure
  • Cardiac
  • Infectious source
  • Neoplasm

Pleural effusion: document if pleural effusion is malignant and document the neoplasm.

Adult (main)|Pediatrics (main)

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Document type: Hypovolemic, Cardiogenic, Septic, Posttraumatic

Adult (main)|Pediatrics (main)

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