Pediatric Coding Alert

Hint: It’s not quite as simple as knowing E10 from E11.

As a peds coder, you’re fully aware that while type 1 diabetes is sometimes referred to as juvenile diabetes, type 1 patients are not the only diabetic patients your office sees. That means you know enough to understand the difference between coding E10.- (Type 1 diabetes mellitus) and E11.- (Type 2 diabetes mellitus).

But when electronic medical records (EMRs) often default to E11.-, and when even ICD-10 guideline 4.a.2 notes that E11.- is the default documentation “if the type of diabetes mellitus is not documented,” the potential for miscoding is always there. And that can lead to major problems down the line.

So, to make sure you get your type 1 coding right, here are the four guidelines you need to know to help you resolve diabetes reporting problems before they even begin.

1) Guideline C.4.a.1

This important guideline for peds coders can sometimes lead to problems. That’s because “many associates new to the medical and billing coding field get confused when they see type 1 diabetes mellitus described as ‘juvenile type,’” says Jean Pryor, CPCO, CPMA, CPC, CPB, CPC-I, CRC, CCS-P, CHAP, administrator of CBO Compliance, St. Elizabeth Physicians, Cincinnati.

The guideline explains that “type 1 diabetes mellitus is also referred to as juvenile diabetes” because “most type 1 diabetics develop the condition before reaching puberty.” “This can lead to some coders assuming that in order to have type 1 diabetes, you must be a juvenile. I have seen where some change a diagnosis code for type 2 diabetes to a type 1 diabetic simply based on the age of the patient,” Pryor notes.

However, the guideline goes on to note that “the age of a patient is not the sole determining factor when assigning a diabetes diagnosis.” So, “we need to code based on what is documented and what is appropriate according to the ICD-10 guidelines,” cautions Pryor.

Coding alert 1: While a pediatric patient with diabetes is more likely to be diagnosed with type 1, a diagnosis of type 2 cannot be ruled out. This is borne out by recent statistics provided by the American Diabetes Association (ADA) that note “in 2014-2015, the annual incidence of diagnosed diabetes in youth was estimated at 18,200 with type 1 diabetes, 5,800 with type 2 diabetes” (Source: www.diabetes.org/resources/statistics/statistics-about-diabetes).

2) Guideline C. 4.a.2

As we have already seen, this guideline is also a dangerous one to navigate, as it designates E11.-, or type 2 diabetes, as the default diagnosis when the medical record does not specify the diabetes type.

The consequences of following this guideline blindly can potentially be very problematic. That’s because “if your patients 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,” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

This means “treatments may not be paid, because physician payment is becoming increasingly value-based and payments are risk-adjusted based on patient conditions,” cautions Bucknam. So, it is vitally important that you work with your pediatrician to arrive at the most specific diabetes diagnosis possible for your patient.

3) Guideline C. 4.a.3

This long and somewhat confusing guideline offers instructions for coding medication use in diabetic patients. To unpack the guideline, you need to know something about the three different drugs mentioned in the guideline and the ways they are used to manage the different types of diabetes. This will quickly point you in the direction of the correct Z79.- (Long term (current) drug therapy) code to use in addition to coding the patient’s diagnosis.

Coding for insulin use. Type 1 diabetics, who cannot produce insulin at all, are regarded as insulin dependent and must take this drug throughout their lives, usually via a pump. For long-term insulin use, the guideline tells you to code Z79.4 (Long term (current) use of insulin).