CODING Q&A

Diabetes Coding for ICD-10-CM

SUZANNE L. CORCORAN, COE

Coding and documentation for diabetes and especially diabetic eye disease have changed substantially with the implementation of ICD-10. Here are some considerations to keep in mind.

Q. What are the major differences between ICD-9 and ICD-10 for diabetes?

A. In coding diabetic eye disease, there are many changes. Instead of coding diabetes plus any ocular manifestations as separate codes, ICD-10 has introduced “combination codes” that describe the type of diabetes as well as any retinopathy and edema.

In ICD-9, we coded diabetes as follows, with a fifth digit to identify the type of diabetes.

250.0_ Diabetes mellitus w/o mention of complication or manifestation

250.5_ Diabetes mellitus with ophthalmic manifestations

• 0 – Type II, or unspecified type, not stated as uncontrolled

• 1 – Type I [juvenile], not stated as uncontrolled

• 2 – Type II, or unspecified type, uncontrolled

• 3 – Type I [juvenile], uncontrolled

When there was diabetic retinopathy, we coded also:

362.0 – Diabetic retinopathy

• 362.01 – Background diabetic retinopathy

• 362.02 – Proliferative diabetic retinopathy (PDR)

• 362.03 – Nonproliferative diabetic retinopathy, NOS (NPDR)

• 362.04 – Mild nonproliferative diabetic retinopathy (NPDR)

• 362.05 – Moderate nonproliferative diabetic retinopathy (NPDR)

• 362.06 – Severe nonproliferative diabetic retinopathy (NPDR)

• 362.07 – Diabetic macular edema (DME)

In ICD-10, everything has changed. First, the concept of “controlled” or “uncontrolled” diabetes is not used in ICD-10. Instead, patients are categorized as simply Type 1 or Type 2. There are five categories of diabetes mellitus:

• E08: Diabetes mellitus due to an underlying condition

• E09: Drug or chemical induced diabetes mellitus

• E10: Type 1 diabetes mellitus

• E11: Type 2 diabetes mellitus

• E13: Other specified diabetes mellitus

We are also instructed to code insulin use for Type 2 diabetics (Z79.4) but not for Type 1 diabetics. Additionally, ICD-10 says to use the E11 codes if the record does not indicate the type of diabetes, but does indicate insulin use.

Q. Can you give some examples of typical coding?

A. In most practices, E10 (Type 1) and E11 (Type 2) will be the most common. Instead of coding the diabetes and any manifestations separately, ICD-10 uses combination codes. There are also codes for use when there are other complications, or when there is no complication. Check our examples in the chart below.

Q. One of the biggest changes in ICD-10 is the use of laterality coding. Why is there none here?

A. Good question. Our guess is that, because diabetes mellitus itself is a systemic disease, the authors of ICD-10 did not think to add laterality — even when it would be appropriate. We hope this will be fixed in a future edition of ICD-10.

Of course, a patient may have PDR in one eye and NPDR in the other or moderate NPDR in one eye and severe NPDR in the other. When you have a situation with multiple conditions, code both even though there is no way to distinguish on the claim which eye the code pertains to. This is analogous to how the ICD-9 codes were used. Of course, if you are billing for surgery rather than for an exam, code the condition in the surgical eye only.

Q. How does ICD-10 change documentation requirements?

A. It has always been important to document completely. Now, however, incomplete documentation may mean that the service cannot be coded at all. Notations in the history regarding the type of diabetes and how the systemic diabetes is being treated (eg, diet, oral medication, insulin) are necessary elements in choosing the proper ICD-10 codes. The exam elements, primarily of the posterior segment, should correlate with the impression and plan Documentation in the medical record should address:

History/Review of Systems/Medications

• Which type of diabetes?

• Insulin use (or not)

Exam elements for each eye

• Is there diabetic retinopathy?

• Proliferative or nonproliferative?

• If nonproliferative, is it mild, moderate, or severe?

• Is there macular edema?

Impression

• Stipulate retinopathy, in each eye, if different

• Stipulate macular edema, in each eye, if different.

Some providers clearly document the absence or presence of macular edema in the impression and plan while others only document the presence of macular edema in the exam elements. Since the retinopathy codes stipulate “with or without macular edema,” it is imperative the physician and staff have an understanding of the physician’s preference so that the proper code(s) is chosen.

Q. Where can we get additional help with coding for diabetes and diabetic eye disease?

A. The American Academy of Ophthalmology has a number of resources, many available to non-members as well as AAO members. The AAO’s Diabetes Decision Tree is particularly helpful and may be found at www.aao.org/Assets/8810b98c-6158-444e-883e-c4629df941d3/635672059826530000/persons-with-diabetes-icd-10-physician-decision-tree-pdf?inline=1. The AAO also offers a Subspecialty Quick Guide for retina at www.aao.org/practice-management/coding/icd-10-cm, which you will find helpful.

Corcoran provides many resources: recorded webinars on our Web site at www.corcoranccg.com, live webinar training sessions, and conferences around the country. We also can provide individual training sessions for your practice. Contact us for more information. RP