Diabetes is a disease process that affects the way the body uses glucose and can originate from metabolic (Type 2), auto-immune (Type 1), as a secondary disease process (e.g., steroid-induced, post-pancreatectomy), and as a transient form that develops during pregnancy (gestational).
Diabetes requires balancing diet, exercise, and medical treatment to achieve control of the patient’s blood glucose and the disease process. Many factors can affect the ability to maintain acceptable blood glucose levels including medical non-compliance, acute illness, stress, and other chronic diseases and disorders. Chronic conditions that require long term steroid treatment can affect the patient’s glucose and cause steroid induced diabetes. Maintaining blood sugar control is important in minimizing complications of the disease.
Coding diabetes poses challenges to coders by requiring documentation of many aspects of the disease. It’s important for coders to remember that assignment of diabetic complication codes should only be reported when there is clear and concise documentation of an existing causal relationship between diabetes and the body systems effected.
Assignment of complication codes should only be reported if there is clear documentation of a causal relationship. Terms such as “due to”, “with”, diabetic, “with mention of”, “in the setting of” “associated with” or “in” should all be considered as clear documentation of a correlation of diabetes and the complication. Documentation without the terms above or similar terms interjected between the word diabetes and potential complicating conditions should not be reported as complications of diabetes. A physician query may be required to seek clarification.
As ICD-10 implementation approaches, assigning codes for diabetes will shift the documentation focus from the diabetes control to whether the patient has any associated diabetic complications. The combination codes include the type, affected body system, and any complications that are associated with the patient’s diabetes.
Per the ICD-10 Official Coding Guidelines 4.a.2, if the type of diabetes is not documented the default is “Type 2 Diabetes”.
1) Type 1 diabetic admitted in DKA with coma. The patient’s insulin pump motor failed while asleep at home, resulting in no insulin delivery.
· ICD-9-CM: 996.57, 250.33, E879.9, E849.0, V58.67
· ICD-10-CM: T85.614A, T38.3X6A, E10.11
2) Patient arrives to the clinic for her 3 month follow-up appointment. The patient is 6 months status post partial pancreatectomy, now with associated diabetes. Overall she is adjusting well and has maintained good control of her blood glucose levels.
· ICD-9- CM: 251.3, 249.00, V88.12
· ICD-10-CM: E89.1, E13.9, Z90.411
3) Patient arrives to the clinic for her 3 month follow-up appointment. The patient has CKD Stage 4 and polyneuropathy related to her uncontrolled DM2.
ICD-9-CM: 250.62, 357.2, 250.42, 585.4
ICD-10-CM: E11.42, E11.22, N18.4