Home Health ICD-9/ICD-10 Alert

Question: Our patient has type II diabetes. He has a stage IV diabetic ulcer on his left heel. He also has diabetic neuropathy. We are providing skilled nursing for wound care. How should we code for him?

Georgia subscriber

Answer: Code for this patient as follows:

• M1020a: 250.80 (Diabetes with other specified manifestations; type II or unspecified type, not stated as uncontrolled);
• M1022b: 707.14 (Ulcer of the heel and midfoot);
• M1022c: 250.60 (Diabetes with neurological manifestations; type II or unspecified type, not stated as uncontrolled); and
• M1022d: 357.2 (Polyneuropathy in diabetes).

Your focus of care is the patient’s diabetic ulcer. The ulcer is a manifestation of the diabetes, so you’ll list the diabetes code first (250.80), followed by a code for the ulcer (707.14).

Remember: A pressure ulcer is not a manifestation of diabetes, and you can’t assume that just because a diabetic patient has an ulcer on the foot that it is a diabetic ulcer. In your patient’s case, the ulcer is documented as a diabetic ulcer, but you must be careful to check the documentation to be certain you code accurately for all patients. 

When selecting codes from the 707.x (Chronic ulcer of skin) category to report skin ulcers, take note of the fourth digit. If your code comes from the 707.0 (Pressure ulcer) subcategory, this code can be listed as primary. But codes from the 707.1 (Ulcer of lower limbs, except pressure ulcer) category should be preceded by the code for the causal condition, if known. If not know, you can list the 707.1x code as primary.

Next, you should report your patient’s diabetic neuropathy. You’ll need to list a second diabetes code to indicate that he has a neurological manifestation of his diabetes (250.60). Follow this with 357.2 to specify the manifestation — diabetic neuropathy.

In ICD-10, for this patient you would list the following codes:

• M1020a: E11.621 (Type 2 diabetes mellitus with foot ulcer);
• M1022b: L97.424 (Non-pressure chronic ulcer of left heel and midfoot with necrosis of bone); and
• M1022c:E11.40 (Type 2 diabetes mellitus with diabetic neuropathy, unspecified).

In ICD-10, one code (E11.621) indicates that your patient has type 2 diabetes with a diabetic foot ulcer, but you’ll need to list a second code to further describe the location and severity of the ulcer. 

Tip: Diabetic ulcer severity is one area where your coding specificity will improve in ICD-10, provided the documentation you receive includes the necessary details. If you don’t currently see all of the information you’ll need to select a precise code for these wounds, now’s the time to begin working with clinicians and physicians to improve the medical record.

Diabetic ulcers are not staged, but in ICD-10, you may indicate the severity of the ulcer. A stage IV pressure ulcer means that bone is exposed. If clinical documentation indicates that bone can be observed or palpated, then you know that the ulcer’s severity is at least muscle necrosis, but there may be bone necrosis as well. You should query the assessing clinician for these details.

You can code the severity of non-pressure ulcers based on the clinician’s documentation with the appropriate sixth character. For example, L97.22- (Non-pressure chronic ulcer of left calf). The sixth character options for these ulcers include:

• 1 — Non-pressure chronic ulcer of left calf limited to breakdown of skin
  
• 2 — Non-pressure chronic ulcer of left calf with fat layer exposed
  
• 3 — Non-pressure chronic ulcer of left calf with necrosis of muscle
  
• 4 — Non-pressure chronic ulcer of left calf with necrosis of bone
  
• 9 — Non-pressure chronic ulcer of left calf with unspecified severity
  

Your scenario indicates the ulcer is stage IV so with more clarification from the clinician regarding bone exposure, you could use the sixth character “4.”

You also have an opportunity to be more specific with your diabetic neuropathy coding in ICD-10. In the scenario you describe, the documentation simply states that the patient has diabetic neuropathy, so you’ll report unspecified code E11.40. But with greater detail in the medical record, your coding options can expand to:

• E11.41 (Type 2 diabetes mellitus with diabetic mononeuropathy);
• E11.42 (Type 2 diabetes mellitus with diabetic polyneuropathy);
• E11.43 (Type 2 diabetes mellitus with diabetic autonomic [poly]neuropathy); or
• E11.44 (Type 2 diabetes mellitus with diabetic amyotrophy).