Q&A: Queries for linking cellulitis and diabetes

Q: Consider patients who are admitted with cellulitis and have type 2 diabetes mellitus with no neuropathy or elevated glucose levels. Should coders query the provider to clarify if the cellulitis is caused by the diabetes, or should such a query only be sent if a patient has other complications of diabetes such as hypoglycemia or neuropathy?

A: There is evidence of a correlation between poorly controlled diabetes and cellulitis based on a study published in Diabetes Care in 2021. Researchers conducted a retrospective cohort study and looked at the relationship between glycemic control and the risk of infection. The patient's glycemic control was assessed using hemoglobin A1C, and a search was performed for diagnosis of infections within 60 days from the date that the A1C was drawn. They found a statistically significant association between the incidence of cellulitis and a hemoglobin A1C greater than 7.5. They concluded that there was a 1.1 twofold increased risk of cellulitis for every one-point increase in the hemoglobin A1C. That's pretty significant.

When considering a query for linking the diabetes to cellulitis, we also have to use critical thinking about what other factors could increase the risk of cellulitis. If the patient has been healthy with no other comorbidities or complications and their A1C is normal, I would not send a query.

But we really have to think about how the diabetes could have led to the development of a breakdown in the skin barrier, ultimately causing the cellulitis. Even when the A1C is at an acceptable level and the carrier testing is normal, we have to ask ourselves if we are missing anything else. For instance, did the patient have an increased stressor or dietary issue during the last week or two that may not be reflected in the A1C levels.

We also have to consider what comorbidities a patient with diabetes has. That same study found a two- and three-fold increased risk of cellulitis among patients with Parkinson's disease and peripheral vascular disease (PVD), respectively. They found that the treatment prednisone was associated with an increased risk of cellulitis as well.

If a CDI professional or coder read a patient's H&P and noted a diabetic patient with PVD had a recent respiratory issue requiring treatment with prednisone, they might be more inclined to sending a query to ask for the link between the diabetes and cellulitis. Each case will require individual consideration as to what the etiology of the cellulitis is.

Editor’s note: This question was answered on the ACDIS Podcast by Kelly Sutton, MHL, BSN, RN, CCDS, CCS, a CDI education specialist for ACDIS/HCPro, and was published on JustCoding. Contact her at kelly.sutton@hcpro.com.