Physician Referral Form
Diabetes Self-Management Education (DSME)/
MNT Medical Nutrition Therapy
Fax: 216-591-0320
www.diabetespartnerhip.org/education
By signing this form, I agree that the patient named below needs the following:
1. Group DSME classes offered at the Diabetes Partnership of Cleveland.
2. An individual assessment or re-education, classroom instruction and follow-up after completion of the
classes, which will not exceed 10 hours.
3. Individual Medical Nutrition Therapy sessions - up to 3 hours (diabetes and other nutrition issues)
Patient Name ____________________________________
DOB ________________________
Referral date _____________________ Patient Phone Number____________________
ICD - 10 Code for diabetes: diagnosis/Code __________________/E___________
ICD- 10 Code for nutrition related issue: diagnosis/code ________________/_______
(See reverse side for list)
Lab tests
Result
Date
 A1C
________
________
 Fasting Glucose
Result
Date
________
________
Please attached patient current electronic list of medication or their diabetes care plan.
Complications for this patient: _________________________________________________________
Reason for client referral (more than 1 can apply):
 Recurrent elevation of blood glucose  Recurrent hypoglycemia  Recent hospitalization for DKA or HHNS
 Recurrent use of diabetes services (ER, hospital or physician/clinic visits)  Other_____________________
 Diabetes Education  Re-education  Change in mediation or treatment plan  Medical Nutrition Therapy
Barriers to patient’s ability to learn or perform self-management skills:
 Visual/hearing impairment
 Impaired mental status
 Impaired psychosocial status  Eating disorder
 Impaired mobility
 Learning disability
 Impaired dexterity  Exercise Restriction
Physician signature _______________________________________ Date ______________________
Physician name (print) ______________________________ Physician NPI __________
PLEASE RETURN BY FAX TO:
216-591-0320 (fax)
www.diabetespartnerhip.org/education
DIABETES DIAGNOSIS AND ICD-10 CODE
E08 Diabetes mellitus due to underlying condition
E09 Drug or chemical induced diabetes mellitus
E10 Type 1 diabetes mellitus
E11 Type 2 diabetes mellitus
E13 Other specified diabetes mellitus
E88.81 Metabolic syndrome (cluster of metabolic risks for CVD and type 2 DM)
O24.911 (Unspecified diabetes mellitus in pregnancy, 1st trimester (O24.912 2nd trimester, O24.913 3rd trimester)
R73.09 Other Abnormal glucose
Z86.32 Gestational Diabetes
NUTRITIONAL DIAGNOSIS AND ICD-10 CODE
E28.2 Polycystic Ovaries
E78.2 Hyperlipidemia, mixed
E73 Lactose intolerance
D50 Iron deficiency anemia
D51 Vitamin B12 deficiency
D52 Folate deficiency
D53 Other nutritional anemias
F50.00 Anorexia nervosa, unspecified
F50.02 Anorexia nervosa binge eating/purging type
K21.9 GERD
K50.10 Crohn’s Disease
K51.0 Ulcerative Colitis
K58.9 IBS
K86.1 Chronic Pancreatitis
K90.0 Celiac Disease
K80 Cholelithiasis
K81 Cholecystitis
K82 Other diseases of gallbladder
K85 Acute pancreatitis
K86 Other diseases of pancreas
K87 Disorders of gallbladder, biliary tract and pancreas in diseases classified elsewhere
K90 Intestinal malabsorption
K91 Intraoperative and postprocedural complications and disorders of digestive system, not
elsewhere classified
K92 Other diseases of digestive system
K94 Complications of artificial openings of the digestive system
K95 Complications of bariatric procedures
I50 Heart failure
I70 Atherosclerosis
I42 Cardiomyopathy
I43 Cardiomyopathy in diseases classified elsewhere
I10 Essential (primary) hypertension
I11 Hypertensive heart disease
I12 Hypertensive chronic kidney disease
I13 Hypertensive heart and chronic kidney disease
I15 Secondary hypertension
N18.3 CKD, stage III (moderate)
N18.4 CKD, stage IV (severe)
N18.5 CKD, stage V
N18.9 CKD, unspecified.
R63.4 Abnormal Weight Loss
R63.5 Abnormal weight gain
B20 Human immunodeficiency virus (HIV) disease