Endocrine, Nutritional and Metabolic Diseases (E00-E89)

Presented by Lawrence Santi, DPM, FASPS

November 20, 2014

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4 GUIDELINES AND INSTRUCTIONS FOR CHAPTER 4 (E00-E89)

5 Endocrine, Nutritional & Metabolic Diseases (E00-E89)

• Excludes1: Transitory endocrine and metabolic disorders specific to newborn (P70-P74). These codes cannot be reported together with other codes in this chapter since the two conditions cannot occur together.

6 Endocrine, Nutritional & Metabolic Diseases (E00-E89)

This chapter contains the following blocks:

• E00-E07 Disorders of thyroid gland • E08-E13 mellitus • E15-E16 Other disorders of glucose regulation and pancreatic internal secretion • E20-E35 Disorders of other endocrine glands • E36 Intraoperative complications of endocrine system

7 Endocrine, Nutritional & Metabolic Diseases (E00-E89)

• E40-E46 Malnutrition • E50-E64 Other nutritional deficiencies • E65-E68 Overweight, obesity and other hyperalimentation • E70-E88 Metabolic disorders • E89 Postprocedural endocrine and metabolic complications and disorders, not elsewhere classified

8 E10 Mellitus

Includes: • brittle diabetes (mellitus) • diabetes (mellitus) due to autoimmune process • diabetes (mellitus) due to immune mediated pancreatic islet beta-cell destruction • idiopathic diabetes (mellitus) • juvenile onset diabetes (mellitus) • ketosis-prone diabetes (mellitus)

9 E10 Type 1 Diabetes Mellitus Excludes 1: This means the following codes cannot be reported together with other codes in this chapter since the two conditions cannot occur together. • diabetes mellitus due to underlying condition (E08.-) • drug or chemical induced diabetes mellitus (E09.-) • (O24.4-) • NOS (R73.9) • mellitus (P70.2)

10 E10 Type 1 Diabetes Mellitus

Excludes 1: • postpancreatectomy diabetes mellitus (E13.-) • postprocedural diabetes mellitus (E13.-) • secondary diabetes mellitus NEC (E13.-) • mellitus (E11.-)

11 Diabetic with a Charcot Foot

12 Diabetic Patient With Charcot Changes

In this presentation, we will learn to code using the new ICD – 10 classification a patient who presents with:

1. Diabetes Type I 2. Diabetic Polyneuropathy 3. Charcot Changes 4. Anemia 5. Abnormally high glucose

13 Type I Diabetic with Charcot Foot (INITIAL EXAM)

Consultation:

Referring physician: Dr. XXXXXX

Chief complaint: Mrs. Smith is a 52 year old female who presents for an initial exam with numbness of both feet and a “fallen arch” on the right foot.

14 Type I Diabetic with Charcot Foot

History of present illness: She states that she noticed the change over the last month. The numbness of both feet was present for about 2 years. She is now seeking help because she has difficulty finding a shoe to fit her right foot. Because of the numbness there is no pain, but noticed redness starting. She related no trauma but this foot change is worse.

15 Type I Diabetic with Charcot Foot (INITIAL EXAM)

Assessment: 1. Charcot right foot 2. Type I Diabetic with neuropathy 3. Type I Diabetic with

16 Type I Diabetic with Charcot Foot (INITIAL EXAM)

Plan: 1. Order radiological studies to evaluate right foot 2. Order blood work-up to include Basic Metabolic profile and HgBA1C 3. Rx: Custom-molded shoes to accommodate right foot 4. Patient to return for follow-up in one week

17 Coding This Encounter Using ICD - 9

• Charcot right foot – 713.5 • Type I diabetic with neuropathy – 250.61 • Type I diabetic with neuropathic arthropathy – 250.81 • Polyneuropathy in diabetes – 357.2

18 Coding This Encounter Using ICD - 10

Code for Charcot right foot:

1. Go to chapter 13 – Diseases of the Musculoskeletal System and Connective Tissue (M00 – M99) 2. M14 – in other diseases classified elsewhere 3. Excludes 1: arthropathy in diabetes mellitus (E08 – E13) with 4th character 6

19

Coding This Encounter Using ICD - 10

4. E10.6 - Type 1 diabetes mellitus with other specified complications 5. E10.61- Type 1 diabetes mellitus with diabetic arthropathy 6. E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy Type 1 diabetes mellitus with Charcot’s

ICD – 10 Code for our Charcot foot: E10.610

20 Coding This Encounter Using ICD - 10

Code for type 1 diabetic with polyneuropathy: 1.Go to chapter 4 – Endocrine, nutritional and metabolic diseases (E00 – E89) 2.E10.4- Type 1 diabetes mellitus with neurological complications 3.E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy Type 1 diabetes mellitus with diabetic neuralgia

ICD – 10 code for a type 1 diabetic with polyneuropathy: E10.42

21 Comparing ICD-9 and ICD-10

ICD-9 ICD-10

E10.610 Type I diabetic with Charcot’s 713.5 Charcot foot joints

250.80 Type I diabetic with neuropathic arthropathy

E10.42 Type I diabetic with diabetic 250.61 Type I diabetic with neuropathy polyneuropathy

357.2 Polyneuropathy in diabetes

22 Coding This Encounter Using ICD - 10

The codes for this initial encounter of a type 1 diabetic with a Charcot foot would be:

CPT: 99203 Initial visit

ICD – 10: E10.610 Type 1 diabetes mellitus with Charcot’s joints E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy

23 Type I Diabetic with Charcot Foot (Subsequent Visit)

Chief Complaint: Mrs. Smith is a 52 year old female who presents for a follow-up visit with numbness of both feet and a “fallen arch” on the right foot.

History of present illness: She states that she noticed the change in her right foot over the last month. The numbness of both feet was present for 2 years but is progressively getting worse. The redness, especially in the midfoot area is increasing. She does not recall any trauma to the right foot.

24 Type I Diabetic with Charcot Foot (Subsequent Visit)

Review of tests taken on initial visit:

Radiological: X-rays taken on initial visit reveal degenerative changes in the midtarsal area of the right foot. Soft tissue swelling is also noted in the plantar aspect of the midfoot. These changes are consistent with a Charcot foot.

Hematological: Blood work-up ordered on initial visit revealed the following abnormalities: Hgb. – 10.5; HgBA1c – 8.0; Glucose - 285

25 Type I Diabetic with Charcot Foot (Subsequent Visit)

Assessment: 1. Charcot right foot 2. Type I Diabetic with neuropathy 3. Type I Diabetic with arthropathy 4. Anemia 5. Uncontrolled diabetes

26 Type I Diabetic with Charcot Foot (Subsequent Visit)

Plan: 1. Fitted patient with custom-molded shoes ordered at initial visit. 2. Discussed with patient abnormal blood values. Called primary care provider and referred patient to him for further follow-up of the anemia and the poor glycemic control. 3. Discussed with patient proper nutrition as an aid to control blood sugar. 4. Rx: Metanx, one tablet, bid for one month – to help with the numbness of the neuropathy. 5. Patient to return for follow-up in two weeks.

27 Coding This Encounter Using ICD - 9

• Charcot right foot – 713.5 • Type I diabetic with neuropathy – 250.61 • Type I diabetic with neuropathic arthropathy – 250.81 • Polyneuropathy in diabetes – 357.2 • Acquired hemolytic anemia, unspecified - 283.9 • Abnormal glucose – 790.29

28 Coding This Encounter Using ICD - 10

E10.610 Type 1 diabetes mellitus with Charcot’s joints and E10.42 Type 1 diabetes with diabetic polyneuropathy are carried over from the initial visit.

We now must code for: 1. Acquired hemolytic anemia, unspecified. 2. Abnormal glucose

29 Coding This Encounter Using ICD - 10

Code for acquired hemolytic anemia: 1. Go to Chapter 3 - Diseases of the blood and blood- forming organs and certain disorders involving the immune mechanism (D50-D89) 2. Then go to hemolytic anemias (D55 – D59) 3. D59.9 Acquired hemolytic anemia, unspecified Idiopathic hemolytic anemia, chronic

30 Coding This Encounter Using ICD - 10

Code for abnormal glucose: 1. Go to Chapter 18 - Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) 2. R73.0 Abnormal glucose 3. Excludes1: diabetes mellitus (E08-E13) 4. Since we already have codes E10.610 and E10.42, we cannot use the abnormal glucose code.

31 Comparing ICD-9 and ICD-10 ICD-9 ICD-10 E10.610 Type I diabetic with Charcot’s 713.5 Charcot foot joints

250.80 Type I diabetic with neuropathic arthropathy

250.61 Type I diabetic with E10.42 Type I diabetic with polyneuropathy

357.2 Polyneuropathy in diabetes

283.9 Acquired hemolytic anemia, D59.9 Acquired hemolytic anemia, unspecified unspecified

790.29 Abnormal glucose Included with E10.610 and E10.42

32 Coding This Encounter Using ICD - 10

The codes for this subsequent encounter of a type 1 diabetic with a Charcot foot and acquired hemolytic anemia would be:

CPT: 99213

ICD – 10: E10.610 Type 1 diabetes mellitus with Charcot’s joints E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy D 59.9 Acquired hemolytic anemia, unspecified Idiopathic hemolytic anemia, chronic

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TYPE I DIABETIC IN KETOACIDOSIS WITH

34 TYPE I DIABETIC IN KETOACIDOSIS WITH OSTEOMYELITIS In this presentation, we will learn to code using the new ICD – 10 classification a patient who presents with:

1. Diabetes Type 1 2. 3. 4. Diabetic Neuropathy 5. Obesity 6. Ulceration of the right heel 7. Osteomyelitis of the right heel

35 TYPE I DIABETIC IN KETOACIDOSIS WITH OSTEOMYELITIS

Consultation:

Referring physician: Dr. XXXXXX

Chief complaint: Mr. Jones is a 55 year old male who presents to the Emergency Room with an infected ulceration on the right heel which probes down to bone, a blood sugar of 500 and a temperature of 101.

36 TYPE I DIABETIC IN KETOACIDOSIS WITH OSTEOMYELITIS

History of present illness: Patient states he has had the ulceration on his right heel for about one month and noticed a change in the wound over the past week. He started to develop a temperature over the last two days. His blood sugar has been elevated for about 5 days. When he went for his dialysis today, they referred him to the ER for further evaluation.

37 TYPE I DIABETIC IN KETOACIDOSIS WITH OSTEOMYELITIS

• Ulceration, Wagner grade 3 probes to bone. Wound measures 4.0cm x 3.5cm x 2.0cm. There is necrotic, devitalized tissue in its base. There is a slight amount of cellulitis surrounding the right heel. There is a slight odor noted with serous drainage.

• Vital Signs – Stable; Temperature 101.5; Weight 310 lbs.

Lab work-up: • WBC – 16,000; Glucose – 535; BUN – 96; Creatinine – 7.5 • Urine – Positive for ketones

38 TYPE I DIABETIC IN KETOACIDOSIS WITH OSTEOMYELITIS

Radiological Studies: X-rays of right foot reveals osseous changes of the inferior aspect of the calcaneus, consistent with osteomyelitis. MRI of right foot recommended to confirm this diagnosis.

Neurological Studies:

Tendon reflexes: Patella 2/5, both right and left Achilles 1/5, both right and left Sensory: Decreased vibratory and light touch, both right and left

39 TYPE I DIABETIC IN KETOACIDOSIS WITH OSTEOMYELITIS Assessment: 1. Trophic ulceration of the right heel 2. Osteomyelitis of the right heel. 3. Diabetes Type 1 4. Diabetic ketoacidosis 5. Diabetic neuropathy 6. Diabetic nephropathy 7. Obesity

40 TYPE I DIABETIC IN KETOACIDOSIS WITH OSTEOMYELITIS Plan: 1. Admit with IV Unasyn 3.0gm q6h 2. Medical consult 3. Infectious Disease consult 4. Vascular consult 5. MRI of right foot 6. Once patient medically stable, excisional debridement of necrotic tissue and bone, to include a bone biopsy

41 TYPE I DIABETIC IN KETOACIDOSIS WITH OSTEOMYELITIS

• Ulceration of right heel – 707.14 • Osteomyelitis of right heel – 730.07 • Type 1 diabetes with neuropathy – 250.61 • Type 1 diabetes with ketoacidosis – 250.11 • Nephritis and nephropathy – 583.81 • Morbid obesity – 278.10

42 TYPE I DIABETIC IN KETOACIDOSIS WITH OSTEOMYELITIS

Code for :

When we go to Chapter 12 – Diseases of Skin and Subcutaneous Tissue (L00 – L99) and try to find the code for a diabetic foot ulceration, it will direct us first to Chapter 4 – Endocrine, Nutritional, and Metabolic Diseases (E00 – E89).

43 TYPE I DIABETIC IN KETOACIDOSIS WITH OSTEOMYELITIS Code for : • Go to Chapter 4 – Endocrine, Nutritional and Metabolic Diseases (E00 – E89) • E10.0 – Type 1 diabetes mellitus • 10.6 – Type 1 diabetes mellitus with other specific complications • E10.62 – Type 1 diabetes mellitus with skin complications • E10.621 Type 1 diabetes mellitus with foot ulcer

ICD – 10 code for our diabetic foot ulcer – E10.621

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Coding This Encounter Using ICD - 10 Code for diabetic ulceration on the right heel with bone involvement: • Go to chapter 12 – Diseases of Skin and Subcutaneous tissue (L00 – L99) • L97.0 – Non-pressure chronic ulcer of lower limb • L97.4 – Non-pressure chronic ulcer of heel and midfoot • L97.41 – Non-pressure chronic ulcer of right heel and midfoot • L97.414 Non-pressure chronic ulcer of right heel and midfoot with necrosis of bone

ICD – 10 code for our right heel ulceration with bone involvement – L97.414

45 Coding This Encounter Using ICD - 10

Code for osteomyelitis of the right heel: • Go to Chapter 13 – Diseases of the Musculoskeletal System and Connective Tissue (M00 – M99) • M86.10 – Other acute osteomyelitis, unspecified site • M86.17 – Other acute osteomyelitis, ankle and foot • M86.171 Other acute osteomyelitis, right ankle and foot ICD – 10 code for our osteomyelitis of right heel – M86.171

46 Coding This Encounter Using ICD - 10

Coding for type 1 diabetic with ketoacidosis: • Go to Chapter 4 – Endocrine, Nutritional and Metabolic Diseases (E00 – E89) • E10.0 – Type 1 diabetes mellitus • E10.1 – Type 1 diabetes mellitus with ketoacidosis • E10.10 Type 1 diabetes mellitus with ketoacidosis without coma

ICD – 10 code for our type 1 diabetic with ketoacidosis – E10.10

47 Coding This Encounter Using ICD - 10 Coding for type 1 diabetic with nephropathy: • Go to Chapter 4 – Endocrine, Nutritional and Metabolic Diseases (E00 – E89) • E10.0 – Type 1 diabetes mellitus • E10.2 – Type 1 diabetes mellitus with kidney complications • E10.21 Type 1 diabetes mellitus with diabetic nephropathy

ICD – 10 code for our type1 diabetes with nephropathy – E10.21

48 Coding This Encounter Using ICD - 10 Coding for type 1 diabetic with polyneuropathy: • Go to chapter 4 – Endocrine, nutritional and metabolic diseases (E00 – E89) • E10.4 - Type 1 diabetes mellitus with neurological complications • E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy Type 1 diabetes mellitus with diabetic neuropathy ICD – 10 code for our type 1 diabetic with polyneuropathy - E10.42

49 Coding This Encounter Using ICD - 10

Coding for obesity: • Go to Chapter 4 – Endocrine, Nutritional and Metabolic Diseases (E00 – E89) • E66.0 – Obesity due to excess calories • E66.01 Morbid obesity due to excess calories

ICD – 10 code for our morbid obesity – E66.01

50 Comparing ICD-9 and ICD-10

ICD - 9 ICD - 10

707.14 Ulceration of heel E10.621 Diabetic foot ulcer

L97.414 Ulceration of right heel and midfoot with bone necrosis

730.07 Osteomyelitis of foot and M86.171 Acute osteomyelitis of ankle right ankle and foot

250.61 Type 1 diabetes with E10.42 Type 1 diabetes with neuropathy polyneuropathy

51 Comparing ICD-9 and ICD-10

ICD - 9 ICD - 10

250.11 Type 1 diabetes with E10.10 Type 1 diabetes with ketoacidosis ketoacidosis

E10.21 Type 1 diabetes with 583.81 Nephritis and nephropathy nephropathy

278.10 Morbid obesity E66.01 Morbid obesity

52 Coding This Encounter Using ICD - 10 The codes for this initial hospital encounter of a type 1 diabetic in ketoacidosis with osteomyelitis and morbidly obese would be:

CPT: 99222 Initial hospital encounter

ICD – 10: E10.621 Diabetic foot ulcer L97.414 Ulceration of right heel with bone necrosis M86.171 Acute osteomyelitis of right foot

53 Coding This Encounter Using ICD - 10

E10.42 Type 1 diabetes with polyneuropathy E10.10 Type 1 diabetes with ketoacidosis E10.21 Type 1 diabetes with nephropathy E66.01 Morbid obesity

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Questions?

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Signs & Symptoms (R00-R99) December 18, 2014

Presenter: Mitchell Hilsen, DPM

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(Webinar topics and dates subject to change)

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