MDS Alert

Use these hints to navigate diabetes complications and treatments.

With the Patient-Driven Payment Model (PDPM) coming down the pike, understanding and using ICD-10 coding will be crucial for accurate reimbursement. For chronic and complicated conditions like diabetes, it’s especially important to understand how different presentations of the disease affect the code you choose.

So, these five basic coding hints will help you streamline the way you code this prevalent condition that now affects so many. Remember, though you don’t necessarily need to know the ICD-10-CM system as well as a professional coder, PDPM relies much more heavily on ICD-10 coding for reimbursement.

“The need for accuracy and specificity is huge – the proper ICD-10 code will be used to determine the primary reason for the SNF PPS stay; the comorbidities must be captured as well. ICD-10 coding will drive reimbursement,” says Jane Belt RN, MS, RAC-MT, RAC-CT, QCP, curriculum development specialist at the American Association for Nurse Assessment Coordination (AANAC) in Columbus, Ohio.

Code for Diabetes Type

Figuring out which diabetes codes make sense in the long-term care environment can be overwhelming initially, but you can quickly narrow down the diabetes code choices by bypassing three of the five diabetes categories that are rarely used in the long-term care setting:

• Category E08 (Diabetes mellitus due to underlying condition),
• Category E09 (Drug or chemical induced diabetes mellitus) or
• Category E13 (Other specified diabetes mellitus).

This leaves you with two main ICD-10 categories for the two main types of diabetes: E10 (Type 1 diabetes mellitus) and E11 (Type 2 diabetes mellitus).

Beware: Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, manager of clinical compliance with PeaceHealth in Vancouver, Washington, reminds coders and providers not to fall back on coding E11 as the default for the condition. “If your [residents] have type 1 diabetes, their care will be much more complex, and this will not be supported if the diagnosis doesn’t match the treatment.”

Consider Control

Joy Dugan and Jay Shubrook, authors of “International Classification of Diseases-10 Coding for Diabetes” (http://clinical.diabetesjournals.org/content/diaclin/early/2017/08/10/cd16-0052.full.pdf), then suggest looking at the level or degree of diabetes control.

ICD-10 does not include any explicit reference to controlled or uncontrolled diabetes. However, the level of control is indicated as a complication in the fourth and fifth characters: EXX.64X in the case of hypoglycemia (blood sugar levels below 70 mg/dl), and EXX.65 for hyperglycemia (blood sugar levels above 130 mg/dl).

Another fourth character, 9, indicates that the condition is controlled (e.g. E10.9 (Type 1 diabetes mellitus without complications)). But using 9 “should be the exception rather than the rule,” according to Dugan and Shubrook, “given that most people with diabetes have either suboptimal control, complications, or both.”

Look for Drug Use

In order to manage their diabetes, residents may require insulin. As this is not indicated in the E11 codes,  Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California, suggests keeping Z79.4 (Long term (current) use of insulin) or Z79.84 (Long term (current) use of oral hypoglycemic drugs) at your fingertips when coding diabetic residents.

Note: There is no corresponding instruction for the E10 codes, as Type 1 diabetes is understood to be insulin-dependent.

Dugan and Shubrook also note that “long-term” simply means that the drug therapy is intended for an extended duration, and the code can be used immediately once the drug use begins.

Note Complications

This is the tricky part, because the complications are numerous. So, Johnson suggests being “on the lookout for co-diseases such as thyroid disease, hearing loss, cancer, neuropathy, feet ulceration, hypertension, etc.” Many can be coded with the following fourth-digit E10 and E11 subdivisions:

• EXX.1- - ... with ketoacidosis
• EXX.2- - ... with kidney complications
• EXX.3- - ... with ophthalmic complications
• EXX.4- - ... with neurological complications
• EXX.5- - ... with circulatory complications
• EXX.6- - ... with other specified complications (includes musculoskeletal, oral, and skin complications; hypoglycemia; and hyperglycemia)
• EXX.8- - ... with unspecified complications.

The only exception to this sequence is E11.0- (Type 2 diabetes mellitus with hyperosmolarity), as this complication, where extremely high blood sugar levels occur without the presence of ketones, is unique to type 2 diabetes.

Don’t Forget Comorbidities

Diabetes is also often linked to many other diseases, so it is important to code them as well. Among the most common are:

• E66.- - Overweight and obesity
• E78.- - Disorders of lipoprotein metabolism and other lipidemias 
• I10 - Essential (primary) hypertension
• L97.- - Non-pressure chronic ulcer of lower limb, not elsewhere classified.

Johnson notes that obesity and type 2 diabetes go hand in hand. “We need to code for this condition as well as BMI (body mass index) if noted,” she says, adding that coders should “code as many codes as necessary to describe all complications and associated conditions and sequence them based on the reason for the encounter.”

As a final note, Bucknam reminds coders why they should code so specifically: “More and more payers are requiring specific diagnoses to support the need for treatments and supplies,” she says, adding that “providers also need to improve the specificity of their diagnosis documentation as physician payment becomes increasingly value-based and payments are risk-adjusted based on patient conditions.”