If the type of diabetes mellitus is not documented in the medical record, what is the default code used?

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The correct answer is E11.- because it represents type 2 diabetes mellitus, which is the most common form of diabetes. In coding practices, when the specific type of diabetes mellitus—such as type 1 or type 2—is not documented in the medical record, the coding guidelines direct coders to use E11.- as the default code. This approach reflects the statistical prevalence of type 2 diabetes in the population, making it a reasonable assumption in the absence of specific documentation. Other codes, like E10.- for type 1, E13.- for other specified types, and E09.- for drug-induced diabetes, are designated for more specific scenarios, which is why they are not used as defaults when the type is unrecorded.

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