ICD 10 Coding Alert

Specificity should be top priority for providers and coders.

Do you code type 2 diabetes? Do you see providers document the condition as “uncontrolled” even though that category is no longer a classification option in ICD-10? Does that burn your biscuits?

Find out how to educate providers with these tips from Colleen Gianatasio, MHS, CPC, CPC-P, CPMA, CRC, CCS, CCDS-O, AAPC Approved Instructor, which she provided in her presentation “Advanced Coding: Diabetes” at RISKCON 2021.

To prevent your biscuits from burning further, look to provider education, Gianatasio says. But rather than overwhelm providers with information about the 300-plus ICD-10-CM diabetes codes, Gianatasio recommended that coders break down the major diabetes code groups for providers so that they understand how the codes function. That means acquainting providers with the use of the following 4th character in both the E10.- (Type 1 diabetes mellitus) and E11.- (Type 2 diabetes mellitus) codes, so that providers understand the major diabetes classifications.

4th Character As 2: Nephropathy and CKD Complications

“Worldwide, diabetes is the top cause of chronic kidney disease (CKD) and end-stage renal disease,” Gianatasio pointed out. But correctly using this 4th character only paints half the picture if your patient has CKD, because the note accompanying E10.22/ E11.22 (Type 1/Type 2 diabetes mellitus with diabetic chronic kidney disease) tells you to use an additional code to identify the stage of kidney disease, if known, using a code from N18.1-N18.6 (Chronic kidney disease, stage 1-End stage renal disease) for greater specificity.

4th Character As 3: Vision Complications

“Diabetes is also one of the most important causes of vision loss worldwide,” Gianatasio noted. Specificity for this complication means coding for type (retinopathy or macular edema); severity (mild, moderate, nonproliferative, and proliferative); and location using 7th characters for right (1) and left (2) eyes, bilaterality (3), and unspecified eye (9).

4th Character As 4: Neurological Complications

These conditions are “some of the most common complications of diabetes,” according to Gianatasio. So, you and your provider should become proficient in documenting the kind of neuropathy (mononeuropathy, polyneuropathy, autonomic (poly)neuropathy, or amyotrophy) complicating your patient’s diabetes.

4th Character As 5: Circulatory System Complications

Before using this character, you and your provider should understand the difference between coding for the peripheral vascular system (veins and arteries in the legs, feet, arms, and hands) and the central vascular system (veins and arteries in the torso). Peripheral vascular disease (PVD), coded to E10.51 or E10.52 and E11.51 or E11.52, is “severely underdiagnosed and [under]coded,” according to Gianatasio.

4th Character As 6: Other Specified Complications

Providers and coders should use this digit for arthropathy (reported with 5th character 1), skin complications (reported with 5th character 2), oral complications (reported with 5^th character 3), hypoglycemia (reported with 5th character 4), and hyperglycemia (reported with 5th character 5). You and your provider will also use E10.69 or E11.69 (Type 1/2 diabetes mellitus with other specified complication) for patients with other complications that are specified in the patient’s health record, though the note accompanying the code tells you that you will require an additional code to document the complication. So, you and your provider should document E10.69 or E11.69 with I10 (Essential (primary) hypertension) for a patient diagnosed with diabetes and hypertension.

Remember: don’t assume NEC causality. “The ‘with’ guideline (ICD-10 guideline I.A.15) does not apply to “not elsewhere classified (NEC) index entries. Specific conditions must be linked by the terms ‘with,’ ‘due to,’ or ‘associated with.’ So, you should not assume a causal relationship when the diabetic complication is NEC,” Gianatasio said.

Why Specificity Is So Important in Diabetes Coding

Stressing to your provider that these conditions justify the need for specific — and very different — diagnosis codes is tremendously important for risk adjustment purposes, Gianatasio argued. This is why you should avoid the unspecified diabetes complications codes (E10.8 or E11.8) if at all possible.

Remember These Characters, too

Uncontrolled diabetes is no longer classifiable in ICD-10. Inadequately controlled, out-of-control, or poorly controlled type 1 or type 2 diabetes supports E10.65 or E11.65 (Type 1/2 diabetes mellitus with hyperglycemia). And if the only provider documentation you have is controlled diabetes, you should code E10.9/ E11.9 (Type 1/2 diabetes mellitus without complications), according to Gianatasio.

Always Focus on the Documentation

Justifying each code means documentation. One way that can be accomplished is through a progress note that covers the four factors outlined by the MEAT (Monitor. Evaluate. Assess/ Address. Treat) acronym, according to Gianatasio. For type 2 coding, that means:

• M: HbA1C, trending glucose levels, urinalysis
• E: Metabolic profiles
• A: Fundoscopic examination, vascular and neurological examination, other organ systems as applicable
• T: Medications directed toward glycemic control and to address chronic complications, education, or referrals to specialist for further treatment.