Coding, Classification and Reimbursement

Diabetes "question"

  • 1.  Diabetes "question"

    Posted 10-13-2016 10:10

    I would like some input regarding the "with" sub-entries under Diabetes.

    I have had some coders ask me if "everything" should be combined with diabetes now and if the condition isn't specified should it go under the NEC codes.  For example, if a patient has diabetes and glaucoma but the physician did NOT link it should they code E11.39 Diabetes with Opthalmic complication NEC and H40.9 glaucoma anyways.  In my opinion no, the NEC codes should be used only if the physician specified a condition is linked to diabetes that does not have its own sub-entry under DM, "with".  Otherwise, the condition is not assumed and should be not be coded as such.

    However, the other thought never crossed my mind so I wanted to get others interpretation of this issue.

    Thanks for your input!

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    Monica Evans
    Coding Educator
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  • 2.  RE: Diabetes "question"

    Posted 10-13-2016 11:24

    Hi Monica- I agree with you. I do not assume any condition is related that is not specifically indexed/identified in the index. As per coding clinic 2nd Q 2016: "For conditions (my emphasis) not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related."

    I believe, like you, that those NEC codes are there for the times the provider documents the association for myriad conditions that can possibly be affected by DM- otherwise, how would we document it as a diabetic co-morbidity? These codes are a catch-all for these situations.

    Additionally, as described in the original coding clinic from 1st Quarter 2016:  "The classification assumes a cause and effect relationship between diabetes mellitus and certain diseases of the kidney, nerves, and circulatory system." So, again, they are saying we can assume a relationship only between the conditions specifically identified under the sub-term "with". 

    I hope this makes sense.

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    Jodi Kingley, CCS
    Inpatient Coder
    Princeton HealthCare System



  • 3.  RE: Diabetes "question"

    Posted 10-13-2016 11:52
    With tongue firmly in cheek--I have diabetes, and I affirm to you that my PMD blames everything on that condition! If I get a cold or a hangnail, it must be because my b. g. control has slipped.

    This does NOT mean I advocate coding this way!

    Sent from my iPod





  • 4.  RE: Diabetes "question"

    Posted 10-13-2016 12:07

    Oh my!  If only we had that much influence over what our bodies do!

    Monica

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    Monica Evans
    Coding Educator



  • 5.  RE: Diabetes "question"

    Posted 10-13-2016 12:05

    2017 Coding Guidelines state

    With - the word 'with' should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alpha Index,  or an instructional note in the Tabular List...

    The index lists DM with ophthalmic complications.  The Code Titles in the Tabular List includes cataracts, macular edema, retinopathy and other ophthalmic complications - all are referred to as diabetic complications.  Since glaucoma is included in E10.39, I would say glaucoma is related to diabetes and I would code it as a diabetic complication.

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    Julianna Perez
    Manager, Medical Records



  • 6.  RE: Diabetes "question"

    Posted 10-13-2016 13:12

    Juliana:

    If the provider has linked the glaucoma to diabetes, then yes, you would use that code. If there is no linkage, you would not use that diabetic code and would code the glaucoma and diabetes separately. Note that retinopathy is a specifically indexed under the subterm "with". Because that specific diagnosis is listed, we can assume a linkage. Otherwise, we can't assume. The opthalmic complication NEC covers anything the provider specifically links, and as per usual coding guidelines, we would include the specific complication as an additional diagnosis. All that tabular note is saying is, yes, glaucoma would be included under the opthalmic complication code. 

    Until coding clinic or a new guideline comes out saying we can link all kidney, eye, circulatory, and nervous diseases with diabetes, it would not be appropriate to do so. As it stands now, they specifically have stated only certain conditions in these disease entities can be automatically linked. And those conditions are listed as specific diagnoses.

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    Jodi Kingley, CCS
    Inpatient Coder
    Princeton HealthCare System



  • 7.  RE: Diabetes "question"

    Posted 10-13-2016 13:20

    I disagree.   in the Index, under with is listed ophthalmic complications.   Glaucoma is an ophthalmic complication.

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    Julianna Perez
    Manager, Medical Records



  • 8.  RE: Diabetes "question"

    Posted 10-14-2016 08:33

    Physician documentation does not need to provide a link between the diagnoses of diabetes and any of the subterms under "with" under the main term Diabetes in the ICD-10-CM Codebook index. If the physician documentation specifies that diabetes mellitus is not the underlying cause of the other condition, then the condition should not be coded as a diabetic complication.

    For example to accurately assign the code E11.40, type 2 diabetes mellitus with neuropathy, the physician documentation does not need to provide a link between the diagnoses of diabetes and retinopathy; this link can be assumed since the neuropathy is listed under the subterm “with.”  Same goes for retinopathy, foot ulcers, cataracts.....and everything else listed under "with".

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    Brenda Mohs
    RHIT
    Essentia Health-Sandstone



  • 9.  RE: Diabetes "question"

    Posted 10-14-2016 10:09

    Yes- as I said above, if a diabetic has any other issue (due to the complication specified, NEC code), we are to code it as diabetes with a complication without the MD making the association unless otherwise contraindicated by the documentation. That is a major change from the original coding clinic and I stand corrected.

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    Jodi Kingley, CCS
    Inpatient Coder
    Princeton HealthCare System



  • 10.  RE: Diabetes "question"

    Posted 10-17-2016 09:29
    Mm

    Sent from my iPhone




  • 11.  RE: Diabetes "question"

    Posted 10-17-2016 10:14

    Sorry about that. I didn't mean to do that "Mm". Sometimes, when you have your hands busier than usual and still carrying a phone. The screen is too sensitive and get into anything without me noticing. Nonetheless, this is the first time that I actually send an email that I didn't mean to neither write or send. My apologies. 

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    MariaClaytorCCSFL



  • 12.  RE: Diabetes "question"

    Posted 10-13-2016 12:05

    Yes, it does make sense!  Thanks so much for your input!

    Monica

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    Monica Evans
    Coding Educator



  • 13.  RE: Diabetes "question"

    Posted 10-13-2016 14:10

    I see your point- so, if we do follow that, all kidney, circulatory,  nervous, opthalmic, oral, skin conditions, and any skin ulcer are automatically linked to diabetes. So, the committee must have changed their mind on certain vs all associated conditions for these areas.  Because the coding clinic was very specific saying only certain conditions in these areas were to be an assumed link.

    I just wonder about the complication -specified, NEC? Would that be the exception to the "with" rule? Basically, that could be anything that is going on with the patient. Which would mean if a diabetic had any other condition in the code book, we would use the E11.69 and not the E11.9 code. This is really throwing me, because it was not what I understood from the coding clinics on this topic:  "The classification assumes a cause and effect relationship between diabetes mellitus and certain diseases of the kidney, nerves, and circulatory system."

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    Jodi Kingley, CCS
    Inpatient Coder
    Princeton HealthCare System



  • 14.  RE: Diabetes "question"

    Posted 10-15-2016 08:01
    Edited by Jodi Kingley 10-16-2016 08:45

    Complications. That is the key word and I can't believe I missed this.

    These codes:

    Diabetes with:

    • circulatory complication  NEC
    • complication and complication specified, NEC
    • kidney complications NEC
    • opthalmic complication NEC
    • etc

    We can not assume these are complications without provider documentation making that clear, either by the provider saying diabetic glaucoma, diabetes complicated by glaucoma, etc., even if it is under "with." Because the patient is not carrying that diagnosis. If they used the term "condition" in the index instead of "complication", that would be a different story. The guidelines are very clear that we can't assume complications and it is up to the provider to make that connection. The diagnoses that we are allowed to assume as connected are specifically listed- e.g. amyotrophy, autonomic (poly) neuropathy, cataract, etc.This is completely consistent with the Coding Clinic on diabetes with associated conditions. 

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    Jodi Kingley, CCS
    Inpatient Coder
    Princeton HealthCare System



  • 15.  RE: Diabetes "question"

    Posted 10-16-2016 20:42

    Thank you!! I too, missed the term ":complications".  I have been trying to make sense of those NEC categories and agree we would have to be coding like the OB cases.

    I like the way you think! 

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    Michele Beneway, CCS
    ICD 10 Mentor



  • 16.  RE: Diabetes "question"

    Posted 10-17-2016 08:54

    Thanks! And you're welcome. I deleted that part about PDx and coding like OB, because I thought my original post was too long and preachy. But I'm glad you agree.

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    Jodi Kingley, CCS
    Inpatient Coder
    Princeton HealthCare System



  • 17.  RE: Diabetes "question"

    Posted 10-17-2016 11:24
      |   view attached

    I just found the following information on Humana's website.  Does everyone agree with this information?  I've attached the file and included the link for the entire document so you can read this in context.

    "The subterm "with" in the index should be interpreted by the coder as a link between diabetes and any condition indented under the word "with." These conditions should be coded as related to diabetes, even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are not caused by diabetes — for example, by stating the actual nondiabetes-related cause or that the cause is not diabetes or the cause is unknown.

    The AHA Coding Clinic states as an example that the physician documentation does not need to provide a link between diabetes and chronic kidney disease to accurately assign code E11.22, Type 2 diabetes mellitus with diabetic chronic kidney disease. This link can be assumed, since chronic kidney disease is listed under the subterm "with" (as long as there is no documentation indicating that CKD is not caused by diabetes)."

    http://apps.humana.com/marketing/documents.asp?file=2665117

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    Jenny Harvey, RHIT, CPHQ, CPMA, CPC
    Manager, Healthcare Consulting
    LBMC

    Attachment(s)