PRESENTED BY: Monique Vanderhoof, RHIT, CPC, CCA, CRCDATE: March 2021

OHSU Health Coder TrainingDiabetes Coding in ICD-10

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These materials were current when published and every reasonable effort has been made to assure the accuracy of the information within these pages. Readers are responsible to ensure they are using the codes and applicable guidelines correctly. OHSU employees, agents and staff make no representation, warranty, or guarantee that this information is error-free and will bear no responsibility or liability for the results of consequences of the use of this course. These materials may not be copied or disseminated without the express written consent of OHSU.

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Diabetes• Diabetes is a disease of the pancreas, an organ behind your stomach

that produces the hormone insulin

• Diabetics have too much sugar in the blood (high blood glucose) because the body’s ability to produce or respond to the hormone insulin is impaired.

• Diabetes is diagnosed using blood tests such as:– Fasting blood sugar - This is the preferred method of diagnosis

diabetes. A blood sample will be taken after an overnight fast.– Glycosylated hemoglobin (HbA1C) - This blood test indicates

your average blood sugar level for the past two to three months.– Random blood sugar - A blood sample is taken at a random

time even when the patient may not have been fasting.

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DiabetesPer Official Coding Guidelines:• Diabetes mellitus codes are combination codes that

include the TYPE of diabetes mellitus, the body system affected, and the COMPLICATIONS affecting that body system.

• They should be sequenced based on the reason for a particular encounter.

• Assign as many Diabetes codes as needed to identify all of the associated conditions that the patient has.

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Diabetes Related Codes

Prediabetes or Borderline Diabetes – R73.03

Impaired fasting glucose – R73.01

• Blood sugar levels are higher than normal, but not high enough to be classified as type 2 diabetes.

Hyperglycemia – R73.9

Hypoglycemia – E16.2

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Diabetes Type 1Type 1 Diabetes – E10._• When the pancreas produces little or no insulin.• Often diagnosed before puberty

Includes:– brittle diabetes (mellitus)– diabetes (mellitus) due to autoimmune process– diabetes (mellitus) due to immune mediated pancreatic

islet beta-cell destruction– idiopathic diabetes (mellitus)– juvenile onset diabetes (mellitus)– ketosis-prone diabetes (mellitus)

.

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Diabetes Type 1Type 1.5 Diabetes – ICD-10 does not recognize this diagnosis specifically!• Latent autoimmune diabetes in adults (LADA), a more slowly

progressive variation of Type 1 Diabetes and includes features of Type 2 Diabetes as well.

• Per Coding Clinic 3rd qtr. 2018, pgs. 4-5– Assign codes from category E13, Other specified diabetes

mellitus, for type 1.5 diabetes mellitus (combined type 1 and type 2).

MODY - This is a rare type of DM!• MODY stands for Maturity Onset Diabetes of the Young

– This would code to an E13 code for other specified DM.– There are actually 11 types of MODY, so I am surprised

we don’t see it more often. Keep your eyes peeled!

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Diabetes Type 2Type 2 Diabetes – E11._• A chronic condition that affects the way the body

processes blood sugar (glucose).Includes:– diabetes (mellitus) due to insulin secretory defect– diabetes NOS– insulin resistant diabetes (mellitus)

** When type of diabetes is not specifically documented the default is Type 2The fact that a patient is receiving insulin does not indicate Type 1 DM.

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Insulin and Medication UseUse additional code to identify use of:

– insulin (Z79.4)– oral antidiabetic/hypoglycemic drugs (Z79.84)– injectable non-insulin drugs (Z79.899)

Remember:• Z79.4 is not required in coding of Type 1 diabetes because use of insulin

is required to sustain life.

• Code Z79.4 should not be assigned if insulin is given temporarily to bring a type 2 patient’s blood sugar under control during an encounter

• If patient is on both insulin and non-insulin injectable drugs code both Z79.4 and Z79.899

• If patient is on both oral hypoglycemic drugs and non-insulin injectable drugs code both Z79.84 and Z79.899

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Insulin ComplicationsComplications due to Insulin Pump Malfunction An insulin pump is a small, computerized device attached to the body that delivers insulin via a catheter. The pump may provide a continuous drip of insulin all day long, or it may allow the patient to self-administer an insulin bolus by pushing a button.

Failure or malfunction of the pump may result in underdosing or overdosing of insulin.

Both of these situations are considered mechanical complications and are assigned a code from subcategory T85.6, Mechanical complication…….category, as the principal diagnosis or first-listed code.

In addition, codes are assigned to specify underdose (T38.3x6-) or overdose (T38.3x1-), as well as the code for the type of diabetes mellitus and any associated complications.

Additional codes for the type of diabetes mellitus and any associated complications due to the under/overdosing should also be assigned.

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Secondary Diabetes

E08 - Diabetes mellitus due to underlying conditionE09 - Drug or chemical induced diabetes mellitusE13 - Other specified diabetes mellitus

Secondary diabetes is always caused by another condition or event • For example: cystic fibrosis, malignant neoplasm of

pancreas, pancreatectomy, adverse effect of drug, or poisoning

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Diabetes Due to Underlying ConditionDiabetes due to underlying condition - E08. _

Code first the underlying condition, such as:– congenital rubella (P35.0)– Cushing's syndrome (E24.-)– cystic fibrosis (E84.-)– malignant neoplasm (C00-C96)– malnutrition (E40-E46)– pancreatitis and other diseases of the pancreas (K85-K86.-)

Use additional code to identify use of:– insulin (Z79.4)– oral antidiabetic/hypoglycemic drugs (Z79.84)

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Diabetes Related to Drug Usage

Drug or chemical induced diabetes mellitus –E09._

Code first:– Code first poisoning due to drug or toxin, if applicable (T36-T65

with fifth or sixth character 1-4 or 6)

Use additional code:Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)

ANDUse additional code to identify use of:– insulin (Z79.4)– oral antidiabetic/hypoglycemic drugs (Z79.84)

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Other Diabetes Other specified diabetes mellitus – E13._

Includes:– diabetes mellitus due to genetic defects of beta-cell function– diabetes mellitus due to genetic defects in insulin action– postpancreatectomy diabetes mellitus

• For postpancreatectomy diabetes mellitus (lack of insulin due to the surgical removal of all or part of the pancreas), assign code E89.1,Postprocedural hypoinsulinemia. Assign a code from category E13 and a code from subcategory Z90.41, Acquired absence of pancreas, as additional codes.

– post procedural diabetes mellitus– secondary diabetes mellitus NEC

Use additional code to identify use of:– insulin (Z79.4)– oral antidiabetic/hypoglycemic drugs (Z79.84)

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Diabetes “with”ICD-10-CM presumes a causal relationship between diabetes and several acute and chronic conditions.

Per Coding Clinic, 2nd qtr. 2016: The word "with" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List.

The following example from the Alphabetic Index for the main term "Diabetes" and the sub term "with" demonstrates this linkage:

Diabetes, diabetic (mellitus) (sugar) E11.9

with

amyotrophy E11.44

arthropathy NEC E11.618

autonomic (poly) neuropathy E11.43

cataract E11.36

Charcot's joints E11.610

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Diabetes “with” continuedPer Coding Clinic Continued from previous slide:

The sub term "with" in the Index should be interpreted as a link between diabetes and any of those conditions indented under the word "with." The physician documentation does not need to provide a link between the diagnoses of diabetes and chronic kidney disease to accurately assign code E11.22, Type 2 diabetes mellitus with diabetic chronic kidney disease.

This link can be assumed since the chronic kidney disease is listed under the sub term "with."

These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated and due to some other underlying cause besides diabetes.

For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related."

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Diabetes “with” continuedThis guideline DOES NOT apply to "not elsewhere classified" (NEC) codes

- Coding Clinic, 4th qtr. 2017, pgs. 100-101

Coders should not assume a causal relationship when the diabetic complication is classified as "NEC."

These conditions must be linked in the patient's medical documentation by the terms "with," "due to," or "associated with."

An example is the Index main term Diabetes "with," "skin complication NEC."

To link diabetes and a specific skin complication NEC, such as cellulitis or acne vulgaris, the provider would need to document the condition as a diabetic skin complication.

If you cannot determine whether a condition is related to diabetes mellitus, it is appropriate to query the physician for clarification so that the appropriate codes may be reported.

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Uncontrolled DiabetesUncontrolled diabetes indicates that the patient's blood sugar is not at an acceptable level, because it is either too high or too low.

There is no default code for "uncontrolled diabetes."

If you look for uncontrolled diabetes in the alphabetic index it says:“meaning hyperglycemia or hypoglycemia” (see below)

Therefore if documentation states uncontrolled diabetes without further specification of hyper or hypoglycemia, you cannot code to this level of specificity without additional documentation.

If the documentation is not clear, query the provider for clarification whether the patient has hyperglycemia or hypoglycemia so that the appropriate code may be reported.

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Poorly Controlled DiabetesICD-10 lists poorly controlled diabetes as synonymous with hyperglycemia.

If you look for poorly controlled diabetes in the alphabetic index it says: “code to Diabetes, by type, with hyperglycemia” (see below)

Therefore if documentation states poorly controlled diabetes it is okay to follow the index and code to diabetes with hyperglycemia.

Also note, the same rule applies for documentation of diabetes out of control and inadequately controlled as it does to poorly controlled. Just follow the index.

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Diabetes Related to ChildbirthDiabetes mellitus inevitably complicates the pregnant state and/or is aggravated by the pregnancy

Pregnant women who have diabetes mellitus should first be assigned a code from category O24, followed by the appropriate diabetes code(s).

Similar to hypertension, category O24 distinguishes between pre-existing diabetes mellitus (including type 1, type 2, other, or unspecified), gestational diabetes, and unspecified diabetes as follows:

O24.011-O24.03 Pre-existing type 1 diabetes mellitusO24.111-O24.13 Pre-existing type 2 diabetes mellitusO24.311-O24.319 Unspecified pre-existing diabetes mellitusO24.410-O24.439 Gestational diabetes mellitusO24.811-O24.83 Other pre-existing diabetes mellitusO24.911-O24.93 Unspecified diabetes mellitus

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Diabetes Related to ChildbirthGestational Diabetes - O24.4 is assigned for this condition. No other code from category O24 should be used with a code from O24.4.

Subcategory O24.4 is further subdivided on the basis of whether the gestational diabetes occurs in pregnancy, childbirth, or puerperium as well as whether it is controlled by diet or medication (oral medication or insulin).

A diagnosis of gestational diabetes refers to abnormal glucose tolerance that appears during pregnancy in a woman who was not previously diabetic. Gestational diabetes mellitus is not a true diabetes mellitus. It can occur during the second and third trimesters of pregnancy. It is thought to be due to metabolic or hormonal changes that occur during pregnancy.

Gestational diabetes can cause complications in the pregnancy similar to those of pre-existing diabetes mellitus. It also places the woman at greater risk of developing diabetes after the pregnancy.

An abnormal glucose tolerance in pregnancy, without a diagnosis of gestational diabetes, is assigned a code from subcategory O99.81.

Codes O24.4- (gestational diabetes) and O99.81- (abnormal glucose tolerance complicating pregnancy) should never be used together on the same record.

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Diabetes ComplicationsPatients with diabetes are particularly prone to developing complications that affect the kidneys, such as nephritis, nephrosis, or chronic kidney disease.

Nephritis = inflammation of the kidney that develops slowly, over a long period of timeNephrosis = an advanced stage of renal disease characterized by massive edema and marked proteinuria Chronic kidney disease = is often the ultimate progression of such conditions

Patients who have both diabetes and hypertension may develop chronic kidney disease as a result.

In this case, three codes are required: one code for the diabetes with renal manifestation, a second code from category I12 (or I13), and a third code from category N18 to indicate the specific stage of the chronic kidney disease.

However, when the patient has diabetes, hypertension, and chronic kidney disease and the provider documents a causal relationship between the diabetes and the chronic kidney disease in terms such as "diabetic CKD" or "diabetic nephropathy," the chronic kidney disease is not coded as hypertensive chronic kidney disease. A code from category I12 or I13 is not assigned; the hypertension is reported separately.

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Diabetes ComplicationsCOMPLICATIONS (for current episode)• With kidney complications

– If kidney disease is NOT due to diabetes, this must be specifically documented.

– Diabetic Nephropathy– Diabetic Chronic Kidney Disease

• Also code the stage of CKD• Also code Dialysis status when documented

– Diabetes w/other Kidney Complication• Complication must be specified in documentation

– Code for the specific complication» i.e. Proteinuria

Patients with hypertension and diabetes may have CKD as a result– The causal relationship must be documented by the provider!

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Diabetes ComplicationsCOMPLICATIONS (for current episode)• With neurological complications

– Diabetic Neuropathy (be sure to look for laterality when appropriate)• Mononeuropathy

– Bell’s Palsy– Ulnar/Carpal Tunnel Syndrome– Etc.

• Polyneuropathy– Diabetic Amyotrophy– Diabetic Neuralgia– Diabetic Autonomic Neuropathy

• Gastroparesis• Bladder Dysfunction• Cardiovascular• Etc.

– Other

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Diabetes ComplicationsCOMPLICATIONS (for current episode)• With skin complications

– Diabetic Dermatitis– Diabetic Skin Ulcer (see ulcer specificity below)

• Also code the site of the ulcer (foot or other location)– Diabetes w/other Skin Complication

• Complication must be specified in documentation– i.e. diabetic blisters, diabetic dermopathy

Ulcer Specificity:• Look for specificity of chronic skin ulcer vs pressure ulcer• Terms ulcer and wound are commonly used interchangeably, which can

cause confusion and improper reporting of diagnoses.– Wound – an injury that happens traumatically– Ulcer – a break in the skin that fails to heal and is typically more chronic

in nature•

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Diabetes ComplicationsDiabetic retinopathy = a progressive condition that is caused by damage to the blood vessels in the retina when there are high blood sugar levels over an extended period of time.

The retina is responsible for detecting light and converting it to signals that are sent to the brain through the optic nerve. When blood sugar levels are not controlled, the blood vessels of the retina may bleed or leak fluid. In the early stages, there may be no symptoms. As the condition worsens, vision may blur, floaters may be seen, or there may be an empty spot at the center of the individual's vision.

Mild nonproliferative diabetic retinopathy = early stage, characterized by venous dilatation, retinal edema, small aneurysms and the leakage of fluid into the retina.

Moderate stage, the blood vessels hemorrhage and the fluid leaves behind hard exudates of cholesterol and fats that cause obstruction in the severe stage. The retina will show signs of damage and severe hemorrhage. The hard exudates and thickening of the retina cause swelling of the macula, the central part of the retina; vision becomes blurry, wavy, or the appearance of colors changes.

When the vessels of the retina obstruct, and new vessels develop in response to the need for oxygenated blood, the condition has progressed from nonproliferative to proliferative diabetic retinopathy. The new blood vessels however, are fragile and cannot meet the necessary blood supply. Scar tissue forms and increases the risk of retinal detachment.

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Diabetes ComplicationsCOMPLICATIONS (for current episode)• With ophthalmic complications

– must identify site (right, left, bilateral)– Diabetic Retinopathy

• Proliferative (with traction and/or rhegmatognous retinal detachment)

• Non-proliferative (mild, moderate, severe)• With or without macular edema

– Diabetic Cataract– Diabetic Macular Edema, resolved following treatment– Other Diabetic Ophthalmic Complication

• Complication must be specified in documentation– i.e. diabetic glaucoma, etc.

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Diabetes Complications• With circulatory complications

– Diabetic peripheral angiopathy *also identify with or w/out gangrene– Other circulatory complications

• Complication must be specified in documentation

Peripheral vascular disease is a frequent complication of diabetes mellitus.

Arteriosclerosis occurs earlier and more extensively in patients with diabetes.

Coronary artery disease, cardiomyopathy, and cerebrovascular disease are not complications of diabetes and are not included in subcategories E08-E13 with .5-.

These conditions are coded separately unless the physician documents a causal relationship with the diabetes.

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Diabetes ComplicationsOther common chronic complications of diabetes mellitus, besides renal, ophthalmic, neurological, or circulatory, are classified to E08-E13 with .6- as follows:

– E08-E13 with .61- Diabetic arthropathy– E08-E13 with .62- Diabetic skin complications– E08-E13 with .63- Diabetic oral complications

Ulcers of the lower extremities, particularly the feet, are common complications of diabetes.

For a diabetic foot ulcer, a code from E08 through E13 with .621 is assigned first, and an additional code of L97.4- or L97.5- is used to indicate the specific site of the ulcer.

Other diabetic skin ulcers are coded to E08-E13 with .622, with an additional code to identify the site of the ulcer (L97.1-L97.9, L98.41-L98.49). If gangrene is present with the ulcer, assign .52 with the E08-E13 code.

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Diabetes Complications

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Diabetes ComplicationsAcute Metabolic Complications Hyperosmolarity, ketoacidosis, and hypoglycemia are acute metabolic complications.

Diabetes with hyperosmolarity (E08-E13 with .01 or .00) is a condition in which there is hyperosmolarity and dehydration without significant ketosis. This condition most often occurs in patients with type 2 diabetes.

Typical findings for patients with diabetic ketoacidosis (DKA) are glycosuria, strong ketonuria, hyperglycemia, ketonemia (blood ketone), acidosis (low arterial blood pH), and low plasma bicarbonate.

Ketoacidosis is an acute, life-threatening complication of diabetes that occurs most commonly in patients with type 1 diabetes, but it can occur in patients with type 2 diabetes.

When there is not enough insulin in the body for muscle and fat cells to absorb glucose to use for energy, fat is broken down and ketones are released into the bloodstream. In a person with diabetes, ketones build up in the bloodstream. The patient may experience excess thirst, frequent urination, nausea, vomiting, abdominal pain, weakness, and decrease in alertness.

Diabetes with hypoglycemia may occur when an excessive amount of insulin is given, when the patient misses a meal, or when the patient is under stress.

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Documentation/Coding Examples

Examples of supported diagnoses:

All of these examples include M.E.A.T. and support the diagnosis exists and is impacting care for the specific date of service.

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Documentation/Coding Examples

Examples of diagnoses w/o support:

These examples above do not include M.E.A.T.

Action words and adjectives to describe how a diagnosis is being Monitored, Evaluated, Assessed, and/or Treated are key to thorough documentation.

Medication refills, referrals, and lab orders only – are not acceptable M.E.A.T. without action words and/or adjectives to describe the current state of the diagnosis and how it is impacting care for this date of service.

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Documentation/Coding Examples• The acute/chronic nature of a diagnosis also impacts the specificity

of the documentation required.

• Chronic, long-standing diagnoses like CKD, neuropathy, retinopathy, etc. – do not go away and have specific guidelines/timing for follow-up, testing, etc. that is followed. – For these dx more generalized M.E.A.T. is sufficient. (i.e. – DM

w/CKD stage 4 - follow-up with nephrology in 1 month)

• Acute, short-term diagnoses like ulcer, ketoacidosis, etc. – do go away and do not impact care long-term. so documentation for these conditions needs to be more specific to confirm the diagnosis is ongoing and still currently exists.– For these dx more specific documentation is required to

confirm the diagnosis is ongoing and still currently exists. (i.e. –DM w/foot ulcer – wound healing well, follow-up next week)

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M.E.A.T.

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In case all of that wasn’t enough…Consider this…Coding Clinic, 1st qtr. 2020, Pgs. 12-13Question:A patient with a long-standing history of type 2 diabetic polyneuropathy underwent bariatric surgery. The patient no longer requires medication for the diabetes secondary to the significant weight loss, and in fact, the physician documents that the diabetes has resolved. The patient has now developed an ulceration of the right foot with acute osteomyelitis secondary to diabetic polyneuropathy. Would these conditions still be coded as diabetic complications?Answer:Assign codes E11.42, Type 2 diabetes mellitus with diabetic polyneuropathy; E11.69, Type 2 diabetes mellitus with other specified complication; E11.621, Type 2 diabetes mellitus with foot ulcer; M86.171, Other acute osteomyelitis, right ankle and foot; and L97.511, Non-pressure chronic ulcer of other part of right foot limited to breakdown of skin. Assign also code Z98.84, Bariatric surgery status, for the post status weight loss surgery.The patient still has complications associated with the diabetes, even though glucose levels have normalized. Codes from category E11, Type 2 diabetes mellitus are required to capture the diabetic manifestations.

Questions?

THANK YOU!!! HCC Program Manager:

Monique Vanderhoof, RHIT, CPC, CCA, CRC vandermo@ohsu.edu

Next session – April 20, 2021Diagnosis Coding for Vascular Conditions and Skin Ulcers