# Diabetes and Cataracts



## LSFeyka (Jun 21, 2016)

At our practice, we have a patient who is diabetic and has a cataract.  There is no evidence within the records whether this is a "diabetic cataract" or not.  I'm not sure whether to code this patient as E11.36 (type 2 diabetes with diabetic cataract) or E11.9 (type 2 diabetes, no complications) and H26.9 (unspecified cataract).  

My gut says that the former is correct, but there is the possibility that the cataracts are due to something other than diabetes.  I've reviewed the entire file and have not discovered any other details.  The reason I question how to code it is that the doctor's notes state "Patient is unaware of diabetic complications," and then the next line states that the patient has cataracts.


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## tag60 (Jun 21, 2016)

My coding handbook warns not to make assumptions about the type of cataract based on the patient's age or other conditions. It further states that cataracts in patients with diabetes are most often senile cataracts, and ..."a true diabetic cataract is rare, and its code should not be assigned unless the physician clearly identifies it as such." It states senile cataracts are more frequently seen in patients with diabetes, but they are not true diabetic cataracts. So, in your scenario you would code the unspecified cataract, or query the physician as to the type of cataract if you still are unclear.


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## mitchellde (Jun 21, 2016)

According to ICD-10 CM conventions and guidelines.  In the alpha section under the keyword diabetes you see the word "with"  the terms indented under the word with are considered to be automatic causal conditions.  The provider does not need to document the causal relationship.


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## LSFeyka (Jun 22, 2016)

Thank you both for your responses.  Forgive my inexperience, but it appears that these posts contradict each other.  Am I missing something?  

tag60


> My coding handbook warns not to make assumptions about the type of cataract based on the patient's age or other conditions. It further states that cataracts in patients with diabetes are most often senile cataracts, and ..."a true diabetic cataract is rare, and its code should not be assigned unless the physician clearly identifies it as such." It states senile cataracts are more frequently seen in patients with diabetes, but they are not true diabetic cataracts. So, in your scenario you would code the unspecified cataract, or query the physician as to the type of cataract if you still are unclear.



From this, I read to use the separate codes.

mitchellde


> According to ICD-10 CM conventions and guidelines. In the alpha section under the keyword diabetes you see the word "with" the terms indented under the word with are considered to be automatic causal conditions. The provider does not need to document the causal relationship.



But this response seems to indicate the opposite.  Or is this meant to be clarification?  Sorry.  I kind of got "thrown" into coding when the switch to ICD-10 happened, and other than a book and a brief webinar, I'm flying blind.  Thank you again.


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## tag60 (Jun 22, 2016)

I believe this means that if your provider documented "diabetes WITH cataract," then per the guidelines the word "with" is interpreted to mean "associated with" or "due to." So in that case you would code diabetic cataract. I did not read in your post that it was worded this way, but you seemed to say cataract was on a separate line, apart from diabetes (?). Can you give us the exact wording?

My answers are just my understanding after doing some research, and I don't mind being corrected if I'm wrong.


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## mitchellde (Jun 23, 2016)

This is new for ICD-10 CM.  the provider does not have to document the relationship or the word with in the documentation.  If the complication is listed under the term "with" in the alpha section of the code book then it is a presumed causal relationship and does not have to be documented as such in the note.  I contacted the AHA coding clinics on this as I too did not understand it and this was the response I received.  They were very clear in the explanation.  This is very different from the way we were taught prior to ICD-10 CM, and we will need to learn to accept that things are changing!


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## LSFeyka (Jun 24, 2016)

The exact wording is:  

"Diabetes mellitus was diagnosed in 2011.  Eye evaluation 2 weeks ago revealed cataracts.

"He is not aware of diabetic complications."

I don't see a causal relationship noted, but I also don't have formal diagnoses noted in this report yet.  The doctor will dictate them shortly.  

I guess my question is that according to my copy of the guidebook, it appears that they're not connected, but if I read mitchellde correctly, that doesn't matter.  The patient has diabetes AND cataracts, so the causal relationship is inferred?  How interesting.  It's a bit counter-intuitive, isn't it?  But, if that's what AHA says, then that's what goes.  

Thank you both so very much for your help.  I feel so much better knowing that when I have some interesting cases to code I will receive such expert help!  Thank you again!


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## mitchellde (Jun 24, 2016)

Things change.  We must accept that as time goes on Logic will be updated and new instructions will be adopted.  This is just one example of where ICD-10 CM has changed how we will do things from here on out.  Let go of the old and embrace the new!  In actuality it is not that the AHA has made a new rule, they are using a long standing guideline on the word "with" And applying it to a new way of listing the diabetes and manifestations, to put forth the new ICD-10 CM logic that as long as the condition is sequenced under the word with, then the provider documentation does not need to indicate a causal relationship.  
This is so completely contrary to how we have been taught since 1978 that it is hard to accept as a new ruling.  It will take time before everyone accepts this new way of thinking.


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## cherene (Jul 4, 2016)

*Diabetes w/manifestation*



mitchellde said:


> Things change.  We must accept that as time goes on Logic will be updated and new instructions will be adopted.  This is just one example of where ICD-10 CM has changed how we will do things from here on out.  Let go of the old and embrace the new!  In actuality it is not that the AHA has made a new rule, they are using a long standing guideline on the word "with" And applying it to a new way of listing the diabetes and manifestations, to put forth the new ICD-10 CM logic that as long as the condition is sequenced under the word with, then the provider documentation does not need to indicate a causal relationship.
> This is so completely contrary to how we have been taught since 1978 that it is hard to accept as a new ruling.  It will take time before everyone accepts this new way of thinking.



Debra-you mentioned that you contacted the AHA Coding Clinic regarding documentation requirements for DM w/manifestations.  Do you happen to have a copy of the Coding Clinic response?  If you do could you please email a copy to me? chereneg@yahoo.com
Thanks so much!
Cherene


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## sujaya101 (Jul 5, 2016)

*diabetic cataract*

If you have the ability to query your physician, please do that. Diabetes and cataract should clearly be linked together in order for you to report it. You can code E11.8 DM with complicatios. But as coders we need to code to the highest level of specificity.


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## mitchellde (Jul 5, 2016)

Again in this ICD-10 CM era, they do not need to be linked by provider documentation if the condition like cataracts is listed under the word "with" under its main term such as diabetes.  For ICD-9 coding the terms must be linked in the documentation by the provider , in ICD-10 CM coding it does not.  This is stated in the coding guidelines.


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## sujaya101 (Jul 5, 2016)

Correct. However, in this case the provider only stated DM  with complicatios  ( and not DM with cataract)  hence the confusion. Providers should be educated for better documentation as reqd by insurance companies in the light of ICD 10.


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## mitchellde (Jul 5, 2016)

The provider stated the patient had diabetes and had cataracts.  For ICD-10CM this is all you need to code it as diabetic cataracts.


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## Lazarus (Sep 22, 2017)

mitchellde said:


> The provider stated the patient had diabetes and had cataracts.  For ICD-10CM this is all you need to code it as diabetic cataracts.



This is correct. For future reference:

In the 4th qtr 2016 a coding clinic was released stating that:

Diabetic cataract
ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2016 Pages: 142-143 Effective with discharges: October 1, 2016
Question:
We have previously been extensively trained that the diabetic cataract is rare, and may occur with rapid onset in Type I diabetics. Coding Clinic for ICD-9- CM previously informed us that the type of cataract more commonly found in adult diabetic patients is the age-related cataract which is not classified as an ocular manifestation of diabetes. The new "With" guidelines instruct us to link any condition indented under the word "with" to diabetes. In this guideline, all cataracts in diabetic patients are diabetic cataracts. Is there a change in understanding of the pathophysiology of the diabetic cataract, and if so, are all cataracts in diabetic patients now considered diabetic cataracts?

Answer:
The advice published in Coding Clinic for ICD- 9-CM for diabetic cataracts dates back to 1985.* Based on the revised guideline and changes in the understanding of the relationship between diabetes and cataracts, cataracts in diabetic patients should be coded as linked conditions*. Cataracts are considered a major cause of visual impairment in diabetic patients as the incidence and progression of cataract is elevated in patients with diabetes mellitus. Several clinical studies have shown that cataract development occurs more frequently and at an earlier age in diabetic compared to non-diabetic patients.


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## Teflon41960 (Jun 18, 2019)

If we know the type of cataract, should we be also be coding the type along with the  E11.36.  For example if we have a diabetic patient that has a cortical cataract in the right eye, should we code E11.36 and H25.011?


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## sanctusthree@gmail.com (Dec 10, 2019)

Teflon41960 said:


> If we know the type of cataract, should we be also be coding the type along with the  E11.36.  For example if we have a diabetic patient that has a cortical cataract in the right eye, should we code E11.36 and H25.011?


Did you ever get an answer for this question?


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## aubwe2000 (Jan 7, 2020)

Teflon41960 said:


> If we know the type of cataract, should we be also be coding the type along with the  E11.36.  For example if we have a diabetic patient that has a cortical cataract in the right eye, should we code E11.36 and H25.011?


Hello, No you would only code the E11.36.


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## rnease (Feb 29, 2020)

You code both E11.36 and the H cataract code - See Coding Clinic 2019, 2Q, pg 30:
Question:

A type 2 diabetic patient with nuclear sclerotic cataract and primary open-angle glaucoma of the right eye undergoes phacoemulsification with intraocular lens implant and stent. Should the cataract be coded as a diabetic complication?

Answer:
Yes it is appropriate to assign a code for diabetic cataract, based on the relationship between diabetes and cataracts as linked conditions. Assign code E11.36, Type 2 diabetes mellitus with diabetic cataract. In addition, assign codes H25.11, Age-related nuclear cataract, right eye, and H40.1110, Primary open-angle glaucoma, right eye, stage unspecified.

As previously published inc Coding Clinic, Fourth quarter 2016, cataracts are a major cause of impairment in diabetic patients as the incidence and progression is elevated due to the diabetes mellitus.


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