Primary Care Coding Alert

These five numbers will help you locate diabetic complications quickly and easily.

Nowhere is specificity more important than in coding for type 2 diabetes, so why do providers still insist on documenting diabetes as uncontrolled, especially when that is no longer a classification in ICD-10? That was the question Colleen Gianatasio, MHS, CPC, CPC-P, CPMA, CRC, CCS, CCDS-O, AAPC Approved Instructor, posed in her presentation “Advanced Coding: Diabetes” at RISKCON 2021.

The answer to avoiding this issue, according to Gianatasio, lies in provider education. 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 fourth digits in both the E10.- (Type 1 diabetes mellitus) and E11.- (Type 2 diabetes mellitus) codes, so that providers understand the major diabetes classifications.

Fourth Digit 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 fourth digit 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.

Fourth Digit 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 seventh digits for right (1) and left (2) eyes, bilaterality (3) and unspecified eye (9).

Fourth Digit 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.

Fourth Digit 5: Circulatory Complications

Before using this digit, 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 coded,” according to Gianatasio.

Fourth Digit 6: Other Specified Complications

Providers and coders should use this digit for arthropathy (reported with fifth digit 1), skin complications (reported with fifth digit 2), oral complications (reported with fifth digit 3), hypoglycemia (reported with fifth digit 4), and hyperglycemia (reported with fifth digit 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.

(For further information about guideline I.A.15, see the reader question “Understand When ‘With’ Doesn’t Mean ‘Linked’” elsewhere in this issue.)

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 Other Digits

“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.

And Don’t Forget the Documentation

Justifying each code means documentation. One way that can be accomplished is thought 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.