Medicare Compliance & Reimbursement

In other words, in the absence of provider documentation that hypertension is associated with or due to diabetes, you cannot assume that relationship simply because the provider uses the word “with.” Instead, you will need to document the hypertension and diabetes with separate codes appropriate to each, such as I10 (Essential (primary) hypertension) for the hypertension and E11.9 (Type 2 diabetes mellitus without complications) for the diabetes.

Note: “The ‘with’ guideline 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,” explained Colleen Gianatasio, MHS, CPC, CPC-P, CPMA, CRC, CCS, CCDS-O, AAPC Approved Instructor, in her presentation “Advanced Coding: Diabetes” at RISKCON 2021.

Question 2: So, does that mean that even though my provider didn’t directly link a patient’s type 1 diabetes with their lactic acidosis, I am correct to report E10.10 (Type 1 diabetes mellitus with ketoacidosis without coma)?

Answer: If the patient suffered diabetic ketoacidosis (DKA), the answer would be yes. However, in this case, the patient has been diagnosed with type 1 diabetes and lactic acidosis, so using E10.10 (Type 1 diabetes mellitus with ketoacidosis without coma) is incorrect.

DKA is a type of metabolic acidosis caused by an accumulation of ketones when the body cannot supply sufficient glucose to blood cells as a direct result of diabetes. Lactic acidosis, on the other hand, is also a form of metabolic acidosis but is caused by a buildup of lactic acid, which occurs when oxygen levels are low due to intense exercise, carbon monoxide poisoning, or excessive alcohol use.

In other words, diabetes causes DKA, so the relationship can be assumed. Diabetes does not cause metabolic acidosis.

Therefore, you need two separate codes for the patient to indicate that the two conditions are unrelated. You should use E87.2- (Acidosis) along with the suitable code from the E10.- (Type 1 diabetes mellitus) series, provided that this reflects the provider’s documentation.

Excludes1 alert: The note accompanying E87.2 states not to use this code in conjunction with any diabetes mellitus with acidosis codes (E08.1-, E09.1-, E10.1-, E11.1-, or E13.1-).

Question 3: Uncontrolled diabetes has not been classifiable in ICD-10-CM since 2021, so how do I report poorly controlled type 1 or type 2 diabetes?

Answer: Some providers still forget that uncontrolled diabetes is no longer classifiable in ICD-10-CM and still refer to the patient’s condition as “uncontrolled” when writing out their notes. 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).

Similarly, if the documentation proves that the condition is controlled, but there aren’t specifics, you should code E10.9/ E11.9 (Type 1/2 diabetes mellitus without complications), according to Gianatasio.

Question 4: Our providers’ diabetes documentation is all over the place. What are some main points I should touch on to help them better understand what information we need?

Answer: Provider education on diabetes coding can seem like a huge undertaking. Rather than overwhelm them with all the information, try breaking down the major diabetes code groups so providers can see how the codes function. This will mean showing them how the E10.- (Type 1 diabetes mellitus) and E11.- (Type 2 diabetes mellitus) codes use the 4th character.

• 4th character 1: This digit is for ketoacidosis. Use a fifth digit for without coma (0) or with coma (1).
• 4th character 2: This digit is for kidney complications. Use a fifth digit to specify diabetic nephropathy (1), diabetic chronic kidney disease (2), or other diabetic kidney complication (9).
• 4th character 3: This digit is for vision complications. 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 4: This digit is for neurological complications. These are among 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 5: This digit is for circulatory complications. The tricky part here is understanding 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). For example, peripheral vascular disease (PVD), coded to E10.51 (Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene) or E10.52 (… with gangrene) and E11.51 (Type 2 diabetes… without gangrene) or E11.52 (… with gangrene), is “severely underdiagnosed and [under]coded,” according to Gianatasio.
• 4th character 6: This digit is for 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 5th character 3)

○ hypoglycemia (reported with 5th character 4)

○ 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.