• Home
  • About Us
    • Annual Business Report
    • Board Community
    • Board of Directors
    • Bylaws and Strategic Plan
    • Call for Board Nominations
    • Committees
  • Continuing Education
    • Calendar
    • Coding Roundtables
    • On Demand Education
    • Speakers Bureau
  • HIM Careers
    • AHIMA-Certified Health Information Professionals
    • Colleges
    • HI Career Map
    • Job Board
    • Post a Job
    • Registered Apprenticeship Program
  • Members
    • Awards
    • Scholarship
    • Volunteer
  • Resources
    • Advertising Opportunities
    • AHIMA Engage
    • AHIMA Foundation
    • Consumer Engagement
    • Join
    • News
    • Newsletters
  • Contact Us

Diabetes

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”.

Examples:

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

September 25, 2015 Christy

Continuing Education

  • Continuing Education
  • Calendar
  • AzHIMA Fall Meeting
  • Coding Roundtables
    • Volunteer
  • On Demand Education
  • Speakers Bureau

Join and follow us on Facebook

Join and follow us on Facebook

ICD-10 Coding and Documentation Corner

Coding News

  • External Cause Coding and State Edit Questions
  • Hot off the Press – Interim Coding Advice regarding Excludes 1 by NCHC
  • Despite Change, the Future of Coding is Bright

CDI Chat Topics

  • AHIMA’s CDI Infographic on Evolution of CDI
  • CDI & Coder Collaboration Presentation
  • CDI and Coder – Ongoing ICD-10 Education
  • AHIMA’s CDI Journey Infographic
  • CDI Chat

Coding Topics of the Month

  • Physician and Back Office Coding Training 2016
  • Neoplasms
  • Diabetes

Spotlights

  • Have You Had a Turn? Have You Had a Chance to Shine?
  • Are You Using Offshore Vendors for Coding, Transcription or Other Health Services?
  • Out with the Old, In with the New, Here we come 2016
  • The Coders 10 Guiding Principles
  • Student Spotlight

Follow Us

Follow Us EmailFollow Us FacebookFollow Us InstagramFollow Us LinkedInFollow Us Twitter

Search

Copyright © 2021 AzHIMA. All Rights Reserved. Powered by KnowledgeConnex | Privacy Policy