The diagnosis of diabetes (and its related complications) is one of the most common diagnoses that occurs in wound care clinics. As many may have already heard, the US will convert from the current ICD-9-CM coding for diagnoses to the new ICD-10-CM system effective Oct. 1, 2014. This article focuses on important documentation issues for wound care practitioners to consider while preparing for the conversion to the new diagnosis coding system.
Quick Review of ICD-9-CMLet’s take a moment to review the current “buzzwords” used in ICD-9-CM. In the ICD-9-CM coding system, diabetes is found in the 250 category of codes and are five digits in length. The coding instructions found in ICD-9-CM for conditions due to diabetes are to code both the underlying cause (diabetes) and the manifestation (ulcer). There are 10 subcategories for coding diabetes with the appropriate current manifestation in the 250 category: 250.0 — Diabetes without mention of complication 250.1 — Diabetes with ketoacidosis 250.2 — Diabetes with hyperosmolarity 250.3 — Diabetes with other coma 250.4 — Diabetes with renal manifestation 250.5 — Diabetes with ophthalmic manifestation 250.6 — Diabetes with neurological manifestation 250.7 — Diabetes with peripheral circulatory disorder 250.8 — Diabetes with other specified manifestation 250.9 — Diabetes with unspecified complication. When assigning these codes, the diabetes (underlying cause) is sequenced first when reporting these types of conditions. The coding system then directs that the specific code for the manifestation be used as the second code. An example might be a diabetic foot ulcer that would be coded to 250.8X and then a category 707 code for the diabetic ulcer. The codes listed above all require a fifth digit indicating whether the patient is type 1 or 2 and if the diabetes is controlled or uncontrolled. If a patient has secondary diabetes from a disease or drug/chemical, a code is selected from category 249 in the code book. To summarize, the current buzzwords associated with diabetes are: • Clearly defining the manifestation for accurate assignment of the diabetic code subcategories • Type 1 or type 2 diabetes • Insulin dependent or non-insulin dependent • Controlled or uncontrolled • Secondary diabetes due to another condition or drug. Diabetes coding also comes with issues related to the sequencing of the codes for purposes of medical necessity. Some payers require the manifestation be coded in the first position as it is most related to the treatment. Even though the coding rules clearly state that the underlying cause is coded first (then the manifestation), payers may mandate that the manifestation be coded first. The best example of this is for diabetic ulcers. Payers may require the ulcer code be sequenced first, followed by the appropriate 250 category code for the underlying diabetes. Refer to your Local Coverage Determinations to see if there are specific instructions for codes proving medical necessity for certain treatments.
Introduction to ICD-10-CMThe wound care industry will gain many benefits when ICD-10-CM is implemented, so let’s focus on those benefits surrounding diagnosis codes for diabetes. The new codes will be very granular, which means the level of specificity will greatly improve. The new ICD-10-CM diagnosis codes for diabetes have their own subchapter in the endocrine, nutritional, and metabolic diseases chapter. The categories for diabetes in ICD-10-CM are: 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. These categories are further subdivided and can contain up to six characters. The higher the number of characters, the more specific the codes are. The new diabetes codes are combination codes that include the type of diabetes, the body system affected, and the complications affecting that system. It is important to remember that providers can assign as many codes as necessary to fully describe the patient’s diabetic conditions. Here’s an example of a comparison between ICD-9-CM and ICD-10-CM diagnosis codes: ICD-9-CM 250.40 — Diabetes with renal manifestation type 2 not stated as uncontrolled 583.81 — Nephritis and nephropathy not specified as acute or chronic in disease classified elsewhere ICD-10-CM E11.21 — Type 2 diabetes with diabetic nephropathy. The reason for the encounter is the diagnosis that should be sequenced first. (This is important for medical necessity purposes). If the type of diabetes is not documented in the record, coders are instructed to default to type 2 diabetes mellitus. Also, if the documentation does not indicate the patient uses insulin, use the type 2 diabetes codes. There is a code (Z79.4) that is to be used when the patient has long-term current use of insulin. This code should not be used if the patient is using insulin on a temporary basis. Secondary diabetes due to other diseases or drugs is most likely a secondary code using the underlying disease or drug/chemical first as an adverse event or a poisoning or sequelae of poisoning. Controlled versus uncontrolled diabetes has been eliminated and replaced with coding hyperglycemia. Detailed documentation will be necessary for appropriate code assignment. For review, the buzzwords in ICD-10-CM diabetes coding documentation are: • Type of diabetes • Body system affected • Insulin use • Any complications associated with diabetes • Any manifestation of diabetes • If secondary diabetes, provide the disease or drug/chemical causing the secondary diabetes. NOTE: Additional codes in other chapters may have specific combination codes when coding with diabetes. For example, when coding skin ulcers, the ulcer codes require additional specificity of documentation, such as: • Laterality (right or left), skin breakdown, fat exposed, muscle necrosis, bone necrosis, or unspecified severity • Pressure ulcers require the documentation of the specific ulcer stages. There are differences between old diabetes buzzwords and new ones for ICD-10-CM. A few have been outlined in this article. To get started, evaluate current documentation by running a report of the most common diabetic conditions seen. Then, pull some of the medical records to see how well both the etiology and manifestation codes are documented. Review the records to ensure the main reason for the encounter is documented properly. For example, if the reason for the encounter is a wound infection, that should be in the first position for that particular encounter. Now is the time to highlight any needs for documentation improvement and educate to ensure use of accurate and specific etiology and manifestation codes for diabetes. The appropriate documentation will assist in the justification of medical necessity for many treatments. Stay tuned for more ICD-10-CM updates in Today’s Wound Clinic. Donna J. Cartwright is senior director of strategic reimbursement services with Integra LifeSciences Corp., Plainsboro, NJ.
ResourcesCenters for Medicare and Medicaid Services. 2013 ICD-10-CM and GEMs. Accessed online: www.cms.gov. National Center for Health Statistics. ICD-10-CM Official Guidelines for Coding and Reporting 2013. Accessed online: www.cdc.gov/nchs. Cartwright D, Schaum K. ICD-10-CM for Wound Care Workshop.