Documentation details matter for diabetes

Quick, what’s the ICD-9-CM code for diabetes?

I bet you knew it was 250.00.

What’s the ICD-10-CM equivalent? Does ICD-10-CM even have an equivalent, since 250.00 is very vague?

Yes, we do have a default code in ICD-10-CM for those times the physician just doesn’t document anything more than “diabetes”—it’s E11.9. Just like 250.00, E11.9 (type 2 diabetes mellitus without complications) doesn’t really tell us much.

ICD-10-CM includes a greater number of codes for diabetes than ICD-9-CM (which surprises no one). Many of the ICD-10-CM diabetes codes are combination codes that include information about the patient’s diabetes as well as any complications or manifestations. Obviously, E11.9 doesn’t include a lot of detail.

ICD-10-CM divides diabetes into five categories, up from the two we currently have in ICD-9-CM:

• E08, diabetes mellitus due to underlying condition

• E09, drug- or chemical-induced diabetes mellitus

• E10, type 1 diabetes mellitus

• E11, type 2 diabetes mellitus

• E13, other specified diabetes mellitus

I’m not sure why ICD-10-CM skips category E12. Maybe they are leaving it for possible code expansion.

ICD-10-CM diabetes codes include subcategories for:

• Ketoacidosis

• Kidney complications

• Ophthalmic complications

• Neurological complications

• Circulatory complications

All of this sounds great. We’re going to capture more information in one code, we can tell which type of diabetes the patient has, and we can stop haranguing physicians to document controlled or uncontrolled. Those terms aren’t used in ICD-10-CM, but if the physician documents poorly controlled or uncontrolled diabetes, you would report it with a code from the correct type of diabetes with hyperglycemia.

If Erin has poorly controlled type 2 diabetes, you would report E11.65 (type 2 diabetes mellitus with hyperglycemia).

Suppose Erin also had a diabetic foot ulcer. We would also code E11.621 (type 2 diabetes mellitus with foot ulcer).

But we’re not done yet. Under code E11.621, we see a note instructing us to use an additional code to identify the site of ulcer (L97.1-L97.9, L98.41-L98.49). The difference in the two categories is location.

If the physician documents Erin’s ulcer is a diabetic ulcer of the right foot, we need to know which part of the foot. We also need to know the stage. In ICD-10-CM, pressure ulcer codes are also combination codes—you get the site and the stage all at once. Don’t have documentation that says, stage III ulcer? That’s okay. You can look at the documentation (including the nursing notes) for a description of the ulcer. Match the description in the documentation with the code description, and you have your stage.

Let’s say the nurse documented that the fat layer is exposed on Erin’s right heel. We can take the stage from the nurse’s documentation, but not the site. The physician has to document the site. Because our physician knows that, she documents the right heel as the site.

That gives us code L97.412 (non-pressure chronic ulcer of right heel and midfoot with fat layer exposed).

One more thing to note about ICD-10-CM and diabetes—you can no longer assume a relationship between diabetes and gangrene or osteomyelitis. The physician needs to make the connection. Coding Clinic, Fourth Quarter 2013, p. 114, gave us that bad news.

Be sure to keep an eye out for additional guidance between now and October 1. If you want the scoop on ICD-10-CM coding for diabetes, check out the on-demand webcast ICD-10-CM Diabetes: Combine Coding and Documentation for Greater Specificity. Jillian Harrington, MHA, CPC-I, CPC, CPC-P, CCS, CCS-P, MHP, does a great job of breaking down the changes in 60 minutes and (even better) you can train everyone whenever they are available.

Editor's Note: This article was originally published on the ICD-10 Trainer Blog.