Primary Care Coding Alert

Also, gain insight into provider education.

As primary care coders, you’ve likely seen your fair share of diabetes claims. That doesn’t mean you’re confident with coding them, though. With over 250 different diabetes codes and all kinds of subtleties and nuances, it’s no wonder things can get confusing.

To help you brush up on your diabetes diagnosis coding, we’ve gathered a list of frequently asked questions and answered them to help clear up commonly confused concepts.

Question 1: I’m often confused by coding when the conditions are related. For example, if my provider documents hypertension with diabetes mellitus, can I assume, and interpret, that “with” means the same as “associated with” or “due to?”

Answer: This trips a lot of coders up. If you look up “hypertension” in the ICD-10-CM Alphabetic Index, you will not find an entry for hypertension “with diabetes,” which would otherwise be “sequenced immediately following the main term or subterm” per guideline I.A.15. Likewise, if you look up “diabetes” in the Alphabetic Index, you will not find an entry for diabetes “with hypertension.”

Luckily, this is cleared up in ICD-10-CM guideline I.A.15, which states that “the word ‘with’ or ‘in’ should be interpreted to mean ‘associated with’ or ‘due to’ when it appears in a code title, the Alphabetic Index (either under a main term or subterm), or an instructional note in the Tabular List.”

Per guideline I.A.15, “For conditions not specifically linked by these relational terms [i.e., “with” or “in”] in the classification or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related.”

In other words, in the absence of provider documentation that the hypertension is associated with or due to the 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).

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 is not classifiable in ICD-10 as of 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.

• 4^th character 1: This digit is for ketoacidosis. Use a fifth digit for without coma (0) or with coma (1).
• 4^th 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).
• 4^th 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).
• 4^th 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.
• 4^th 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.
• 4^th character 6: This digit is for other specified complications. Providers and coders should use this digit for:

o arthropathy (reported with 5th character 1)

o skin complications (reported with 5th character 2)

o oral complications (reported with 5th character 3)

o hypoglycemia (reported with 5th character 4)

o 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.