Navigate your way to comprehensive documentation and coding A Premera documentation and coding series for practitioners

Diabetes

What you’ll get out of this session:

For clinicians: Understand what needs to be documented for diabetes in order to code to the highest level of specificity

For coders and clinicians: Know how to appropriately code for diabetes

ICD-10: Categories of diabetes

Five categories: E08 – DM due to an underlying condition E09 – Drug or chemical-induced DM E10 – Type I DM E11 – Type II DM E13 – Other specified DM

200+ codes in ICD-10 within these categories

Medical records documentation must be specific to choose the most appropriate code

ICD-9 to ICD-10: More codes

Diabetes Coding Comparison from ICD-9-CM to ICD-10-CM

ICD-9-CM ICD-10-CM

249._ - Secondary diabetes mellitus

E08._ - Diabetes mellitus due to underlying condition E09._ - Drug or chemical induced diabetes mellitus E13._ - Other specified diabetes mellitus

250._ - Diabetes mellitus E10._ - Type 1 diabetes mellitus E11._ - Type 2 diabetes mellitus

648._ - Diabetes mellitus of mother, complicating pregnancy, childbirth, or the puerperium

O24._ - Gestational diabetes mellitus in pregnancy

775.1 - Neonatal diabetes mellitus P70.2 - Neonatal diabetes mellitus

Pre-Diabetes

Coding for pre-diabetes

Don’t code diabetes unless the patient has diabetes

Patient has: Correct codes to use:

Elevated blood glucose level R73. _

Impaired fasting glucose R73.01

Impaired glucose tolerance (oral) R73.02

Other abnormal glucose R73.09

Hyperglycemia, unspecified R73.9

E10 Type I DM and E11 Type II DM

E10 Type I DM and E11 Type II DM

• Specify Type 1 or Type 2 Different types of Type 1 and 2 If not specified, defaults to Type 2

• Document the degree of control ICD-10 eliminated the controlled vs. non-controlled Code either: • completely uncomplicated E11.9 • or, w/hypo or hyperglycemia

• Document complications

E10 Type I DM and E11 Type II DM

• Specify complication to a very specific degree 5 complications of diabetes: • Kidney and renal • Ophthalmic (eye/retinal) • Neurological (nerve) • Circulatory • Other specific (arthropathy, skin, ulcerations, oral/periodontal,

hypoglycemia, hyperglycemia) ICD 10 eliminates the need to report additional codes with exception: • Must list the stage of the CKD and ulcer site Combination codes require proper linking verbiage in documentation to clearly depict the complexity of the condition’s treatment plan

Case Study Examples

Case study example #1

52-year-old male patient with diabetes • Three-month follow up

• Patient has no complaints

• Expanded problem-focused history and physical examination, the

physician documents in the medical record • “Diabetes well controlled with Lantus, diet, and exercise.

Patient to continue with same medication dosage, monitor glucose level with home monitoring system, and return to clinic in three months for re-check to include hemoglobin A1-c, lipids, and urine micro albumin.”

• Referral written to ophthalmology for diabetic eye exam

Case study example #1: correct coding

52-year-old male patient with diabetes • Three-month follow up

• Patient has no complaints

• Expanded problem focused history and physical examination, the physician

documents in the medical record • “Diabetes well controlled with Lantus, diet, and exercise. Patient to

continue with same medication dosage, monitor glucose level with home monitoring system, and return to clinic in three months for re-check to include hemoglobin A1-c, lipids and urine micro albumin.”

• Referral written to ophthalmology for diabetic eye exam • Coding:

• E11.9 – Type 2 diabetes mellitus without complication • Z79.4 – Long-term use of insulin

Case study example #2

• 45-year-old female is seen and evaluated for diabetes mellitus Type 2, poorly controlled

Case study example #2: correct coding

• 45-year-old female is seen and evaluated for diabetes mellitus Type 2, poorly controlled

• Coding: E11.65 – Type 2 diabetes mellitus with hyperglycemia

Case study example #3 and #4

Documentation: Correct code: 3) Female patient with Type 1 diabetes and stage 1 chronic kidney disease (cause and effect not documented)

4) Patient is seen for diabetic chronic kidney disease, stage 3, and takes insulin on a daily basis

Case study example #3 and 4: correct coding

Documentation: Correct code: 3) Female patient with Type 1 diabetes and stage 1 chronic kidney disease (cause and effect not documented)

E10.9 Type 1 diabetes mellitus without complications N18.1 Chronic kidney disease, stage 1

4) A patient is seen for diabetic chronic kidney disease, stage 3, and takes insulin on a daily basis

E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease

N18.3 Chronic kidney disease, stage 3 (moderate)

Z79.4 Long term (current) use of insulin

Linking Verbiage for Complications

Creating a link between diabetes and a complication is not difficult and does not have to be extremely lengthy

For example: “CKD stage IV due to diabetic nephropathy”

Linking Verbiage for Complications

Creating a link between diabetes and a complication is not difficult and does not have to be extremely lengthy

For example: “CKD stage IV due to diabetic nephropathy”

Correct Coding: E11.22 – Type 2 diabetes mellitus with chronic kidney disease N18.4 – Chronic kidney disease, stage 4 (severe)

Expanded DM codes

• Creating a link between diabetes and a complication is not difficult and does not have to be extremely lengthy

• Codes for diabetes mellitus with complications have been expanded in ICD-10

• New categories:

• E11.62X - diabetes with skin complications

• E11.63X - diabetes with oral complications

• E11.61X - diabetes with arthropathy

Additional Coding

Coding E11.2_ – Kidney complications

E11.2 – Type 2 diabetes mellitus with kidney complications: E11.21 – Type 2 diabetes mellitus with diabetic nephropathy • Type 2 DM with inter-capillary glomerulonephrosis • Type 2 DM with intra-capillary glomerulonephrosis • Type 2 DM with Kimmelstiel-Wilson disease E11.22 – Type 2 diabetes mellitus with diabetic chronic kidney disease: • Type 2 DM with CKD due to conditions classified to .21 and .22 • Use additional code to identify stage of CKD (N18.1-N18.6) E11.29 – Type 2 diabetes mellitus with other diabetic kidney complication: • Type 2 DM with renal tubular degeneration

Coding E11.62_ - Skin complications

• E11.621 – Type 2 diabetes mellitus with foot ulcer: ICD-10 requires codes to identify the site Use additional code to note the site of the ulcer (L97.4, L97.5)

• Documentation: “Patient with left foot ulcer due to type 2 DM”

• Code: E11.621 – Type 2 DM with foot ulcer L97.429 – Non-pressure chronic ulcer of left heel and mid-foot with unspecified severity

Coding E11. 5_ - Circulatory complications

• E11.51 - DM with diabetic peripheral angiopathy without gangrene

• E11.52 - DM with diabetic peripheral angiopathy with gangrene

• E11.59 - DM with other circulatory complications (this is unspecified)

E11.4 - Neurological complications

• E11.40 DM with diabetic neuropathy, UNSP

• E11.41 DM with diabetic mononeuropathy

• E11.42 DM with diabetic polyneuropathy Type 2 DM with diabetic neuralgia

• E11.43 DM with diabetic autonomic (poly)neuropathy Type 2 DM with diabetic gastroparesis

• E11.44 DM with diabetic amyotrophy

• E11. 49 DM with other diabetic neurological complication

• Linking neuropathy to diabetes is straightforward with an assessment documented: “diabetes with polyneuropathy”

diabetic polyneuropathy in conjunction with a description of the patient’s symptoms or results of a monofilament exam

Coding E08 – When DM is a complication

• It’s important to code the underlying condition FIRST

• Diabetes should never be used as a primary diagnosis

• This category is reserved for individuals who develop DM as the result of an underlying condition such as malignancy, malnutrition, and pancreatitis

Coding co-morbidities and co-existing conditions

• Coding of diabetes even if the condition is well managed should be done at least once annually, more as necessary

• Remember to thoroughly document each patient’s specific condition Coders need documentation to accurately code patients with additional complications that aren’t listed on your claims It’s also important to remember to code all additional diagnoses

• Most patients who have diabetes often also have hypertension, hyperlipidemia, and obesity and may use tobacco products

Each of these additional issues requires separate coding These additional diagnostic codes may have almost as many combinations as found in the diabetes mellitus codes

For more information about coding diabetes or any other chronic and complex conditions, contact our Provider Engagement Team at 877-342-5258, option 4 email: ProviderEngagement@premera.com online: premera.com/wa/provider/commercial-risk-adjustment/

Navigate your way to comprehensive documentation and coding A Premera documentation and coding series for practitioners

036904 (05-2016)