More than 8% of the population in the United States (i.e., 25.8 million children and adults) hassome form of diabetes, according to the American Diabetes Association. In 2007, diabetes was listed as the underlying cause on 71,382 death certificates. It was a contributing factor on an additional 160,022 death certificates.
If these numbers aren’t staggering enough, take a moment to consider the costs for treatment. In 2012, the total cost of diagnosed diabetes, including direct medical costs and reduced productivity, was $245 billion.
Experts say the only way to combat the disease and its rising costs is to collect and track more specific data that can better pinpoint the causes of diabetes and indirectly assist with interventions. The good news is that as of October 1, 2014, ICD-10-CM makes this task a lot easier.
Diabetes: Clinically speaking
Diabetes is a condition in which a patient’s blood sugar is either abnormally high (hyperglycemia) or abnormally low (hypoglycemia), explains Pamela Rand, RD, LDN, dietitian and certified diabetes outpatient educator in Peace Dale, R.I.
Unregulated blood sugars occur when an individual either:
- Doesn’t produce any insulin to distribute circulating blood glucose, a byproduct of food, into the body’s cells for energy (Type 1 diabetes
- Produces insulin, but the insulin is resistant to circulating blood glucose to cells for energy (Type 2 diabetes)
However, diabetes can also occur due to drugs or chemicals, an underlying condition, or some other cause (e.g., removal of the pancreas, genetic defects in insulin action, or genetic defects of beta-cell function).
Gestational diabetes occurs when women who are pregnant and who don’t have a previous history of diabetes develop a high blood glucose level. This high glucose level may resolve after the baby is delivered.
Diabetes: ICD-9-CM vs. ICD-10-CM
In ICD-9-CM, codes for diabetes distinguish between secondary diabetes (249.xx) and Type 1 or Type 2 (250.xx)diabetes.
The fourth digit for both code categories indicates the presence of a complication. Coders must report an additional code to denote the specific complication. For example, when a patient has secondary diabetes with diabetic cataract, coders must report:
- 249.5x, secondary diabetes with ophthalmic manifestations
- 366.41, diabetic cataract
The fifth digit in code category 249.xx indicates whether the secondary diabetes is
- Not stated as uncontrolled
- Uncontrolled
- Unspecified
The fifth digit in code category 250.xx indicates Type 1 or Type 2 and whether the diabetes is not stated as uncontrolled, uncontrolled, or unspecified.
Diabetes coding in ICD-10-CM
Coders may be surprised by the expansion and reorganization of codes for diabetes in ICD-10-CM, says Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS, senior director of HIM innovation at Nuance Communications in Atlanta.
Not only are the ICD-10-CM codes far more detailed than their ICD-9-CM counterparts, but they also comprise nearly six pages of the ICD-10-CM Manual. Thankfully, the manual includes plenty of instructional notes, she says. Once published, Coding Clinic for ICD-10-CM will also likely provide guidance and examples on which coders can base compliant decisions, she adds.
In ICD-10-CM, codes for diabetes appear in category E08-E13. These codes distinguish between the following types of diabetes:
- Diabetes due to an underlying condition (E08)
- Drug- or chemical-induced diabetes (E09)
- Type 1 diabetes (E10)
- Type 2 diabetes or diabetes not otherwise specified (E11)
- Other specified diabetes (E13)
Note that coders should assign code O24.4- for gestational diabetes and P70.2 for neonatal diabetes.
What will be most striking for coders is the fact that none of the ICD-10-CM codes for diabetes specify whether the condition is uncontrolled-a detail for which coders have become quite accustomed to querying, says Cassidy. Instead, codes focus on and are indexed by type, cause, and complications/manifestations.
Also notable is the fact that Type 1 and 2 diabetes each have their own categories, says Laura Legg, RHIT, CCS, HIM and coding consultant in Renton, Wash. Drug- or chemical-induced diabetes as well as diabetes due to an underlying condition are also separate from secondary diabetes. In ICD-9-CM, secondary diabetes is a “catch-all” category that includes both, she adds.
Researchers will benefit from this enhanced data capture of each specific type of diabetes that can be easily identified by category, says Cassidy.
With greater delineation comes the need for more specific documentation. For example, coders must code first one of the following specific underlying conditions when they report a code from category E08:
- Congenital rubella
- Cushing’s syndrome
- Cystic fibrosis
- Malignant neoplasm
- Malnutrition
- Pancreatitis and other diseases of the pancreas
“It’s really important to know the underlying condition,” says Rand. “The diabetes could be due to acromegaly or pancreatitis, and if those conditions aren’t treated, then the diabetes won’t go away.”
As a dietitian, Rand says she is particularly interested in malnutrition’s relationship with diabetes. “Malnutrition is a serious stress on the body. When you don’t eat enough, there is a mechanism that triggers your liver to produce sugar. However, it produces too much or too little and nothing in between,” she says.
The underlying condition isn’t the only piece of information that coders will need. When reporting E09, coders must code first the specific drug or chemical that causes the diabetes. To do so, they’ll choose a code from category T36-T65.
For example, a physician documents an initial encounter with a patient who has drug-induced diabetes without complications due to an adverse effect of pravastatin. Coders should report T46.6x5 followed by E09.9. Sequencing the codes in this way may seem counterintuitive, and it may also affect the MS-DRG, says Cassidy.
Being able to track the drugs and chemicals that can cause diabetes is extremely valuable, says Rand. It may help researchers determine whether antihypertensive drugs as well as corticosteroids can cause diabetes when taken in high doses, she adds.
“Statins are the most widely prescribed drugs to lower cholesterol, but those drugs also have a side effect that some researchers are noticing can cause high blood sugar,” says Rand.
Incretin mimetics-drugs used to treat Type 2 diabetes-are also under scrutiny, says Rand. “There’s a lot of research that these drugs that are used to treat diabetes can actually damage the pancreas where the insulin is produced,” she adds.
Coders must also report code Z79.4 to denote long-term insulin use, when appropriate. Type 1 diabetes doesn’t require this code. In ICD-9-CM, coders reported V58.67 for this purpose. “The code is different, but the concept is the same,” says Legg.
Another noticeable change in ICD-10-CM is that codes for diabetes are combination codes, meaning they identify both the etiology and any manifestations/complications. For example, only one ICD-10-CM code (E08.351) is necessary to describe diabetes due to an underlying condition with proliferative diabetic retinopathy with macular edema.
This information is invaluable, says Rand. The longer a patient’s glucose levels are uncontrolled, the more likely he or she is to develop a complication, she adds. These codes will allow researchers to compare A1C levels with specific types of diabetes and any ensuing complications.
Rand says she would eventually love to see a combination code that can help track depression as a complication of diabetes. “Depression is equally as related to diabetes as a foot ulcer,” she says.
As with ICD-9-CM, the link between the diabetes and its manifestation/complication must be clear. “Oftentimes, the physician will document the diabetes and the underlying condition, but not tie them together,” says Legg. Coders must continue to query when documentation is vague, she adds.
Start prepping physicians now
It’s never too early to start asking for more specific documentation or incorporating additional elements into electronic health record templates, says Cassidy.
ICD-10-CM will require the following details for diabetes:
- Specific type of diabetes
- Specific type of underlying condition (if applicable)
- Specific type of drug or chemical (if the diabetes is drug- or chemical-induced) as well as how that drug or chemical was taken (e.g., adverse effect vs. poisoning)
- Complications and/or manifestations of the diabetes (including the specific site of an ulcer or stage of chronic kidney disease)
“If physicians don’t provide enough of this specific documentation, coders will have a really big challenge,” says Cassidy.
This article was originally published in the June 2013 issue ofBriefings on Coding Compliance Strategies.