A child is diagnosed with borderline type 2 diabetes and borderline hypertension. Is it correct to report codes for hypertension (I10) and type 2 diabetes without complications (E11.9), or should you consider a diagnosis that includes the term borderline for an uncertain diagnosis? (See Box.) Guidelines for International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) address this question as follows:

Examples of specific index entries for borderline conditions include

Because there are specific index entries for borderline diabetes and hypertension, codes R73.09 (other abnormal glucose) and R03.0 (elevated blood pressure reading without diagnosis of hypertension) would be reported for this scenario. But add a diagnosis of borderline high cholesterol to the scenario and code E78.0 (pure hypercholesterolemia) is reported because no specific index entry is found for borderline high cholesterol. The guidelines specify that coders (who may be wary of reporting a diagnosis...

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