Appendix 535B: Qualifying Diagnosis for Pre-, Diabetes, and Obesity

ICD-9-CM diagnosis codes are effective for dates of service prior to October 1, 2015.

ICD-9 CODE ICD-9-CM DIAGNOSIS CODE DESCRIPTION Diabetes mellitus without mention of complication, type I [juvenile type], not stated as 250.01 uncontrolled 250.03 Diabetes mellitus without mention of complication, type I [juvenile type], uncontrolled 250.11 Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled 250.13 Diabetes with ketoacidosis, type I [juvenile type], uncontrolled 250.21 Diabetes with hyperosmolarity, type I [juvenile type], not stated as uncontrolled 250.23 Diabetes with hyperosmolarity, type I [juvenile type], uncontrolled 250.31 Diabetes with other coma, type I [juvenile type], not stated as uncontrolled 250.33 Diabetes with other coma, type I [juvenile type], uncontrolled 250.41 Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled 250.43 Diabetes with renal manifestations, type I [juvenile type], uncontrolled 250.51 Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled 250.53 Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled 250.61 Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled 250.63 Diabetes with neurological manifestations, type I [juvenile type], uncontrolled Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as 250.71 uncontrolled 250.73 Diabetes with peripheral circulatory disorders, type I [juvenile type], uncontrolled 250.81 Diabetes with other specified manifestations, type I [juvenile type], not stated as uncontrolled 250.83 Diabetes with other specified manifestations, type I [juvenile type], uncontrolled 250.91 Diabetes with unspecified complication, type I [juvenile type], not stated as uncontrolled 250.93 Diabetes with unspecified complication, type I [juvenile type], uncontrolled Diabetes mellitus without mention of complication, type II or unspecified type, not stated as 250.00 uncontrolled 250.02 Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled 250.10 Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled 250.12 Diabetes with ketoacidosis, type II or unspecified type, uncontrolled 250.20 Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled 250.22 Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled 250.30 Diabetes with other coma, type II or unspecified type, not stated as uncontrolled 250.32 Diabetes with other coma, type II or unspecified type, uncontrolled 250.40 Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled 250.42 Diabetes with renal manifestations, type II or unspecified type, uncontrolled Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as 250.50 uncontrolled 250.52 Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled Diabetes with neurological manifestations, type II or unspecified type, not stated as 250.60 uncontrolled 250.62 Diabetes with neurological manifestations, type II or unspecified type, uncontrolled Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as 250.70 uncontrolled

BMS Provider Manual Page 1 Appendix 535B Effective 4/1/2017

Appendix 535B: Qualifying Diagnosis for Pre-Diabetes, Diabetes, and Obesity

250.72 Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled Diabetes with other specified manifestations, type II or unspecified type, not stated as 250.80 uncontrolled 250.82 Diabetes with other specified manifestations, type II or unspecified type, uncontrolled 250.90 Diabetes with unspecified complication, type II or unspecified type, not stated as uncontrolled 250.92 Diabetes with unspecified complication, type II or unspecified type, uncontrolled 278.00 Overweight and obesity 278.00 Obesity, unspecified convert 278.01 Morbid obesity 278.02 Overweight

ICD-10-CM diagnosis codes are effective for dates of service on and after October 01, 2015.

ICD-10 CODE ICD-10-CM DIAGNOSIS CODE DESCRIPTION

E10.10 mellitus with ketoacidosis without coma E10.11 Type 1 diabetes mellitus with ketoacidosis with coma E10.21 Type 1 diabetes mellitus with E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease E10.29 Type 1 diabetes mellitus with other diabetic kidney complication E10.311 Type 1 diabetes mellitus with unspecified with macular E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema E10.321 Type 1 diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema Type 1 diabetes mellitus with mild non-proliferative diabetic retinopathy without macular E10.329 edema Type 1 diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular E10.331 edema Type 1 diabetes mellitus with moderate non-proliferative diabetic retinopathy without macular E10.339 edema E10.341 Type 1 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema Type 1 diabetes mellitus with severe non-proliferative diabetic retinopathy without macular E10.349 edema E10.351 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema E10.359 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema E10.36 Type 1 diabetes mellitus with diabetic cataract E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication E10.40 Type 1 diabetes mellitus with , unspecified E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy E10.44 Type 1 diabetes mellitus with diabetic amyotrophy E10.49 Type 1 diabetes mellitus with other diabetic neurological complication E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene

BMS Provider Manual Page 2 Appendix 535B Effective 4/1/2017

Appendix 535B: Qualifying Diagnosis for Pre-Diabetes, Diabetes, and Obesity

ICD-10 CODE ICD-10-CM DIAGNOSIS CODE DESCRIPTION

E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.59 Type 1 diabetes mellitus with other circulatory complications E10.610 Type 1 diabetes mellitus with diabetic neuropathic E10.618 Type 1 diabetes mellitus with other diabetic arthropathy E10.620 Type 1 diabetes mellitus with diabetic dermatitis E10.621 Type 1 diabetes mellitus with foot E10.622 Type 1 diabetes mellitus with other skin ulcer E10.628 Type 1 diabetes mellitus with other skin complications E10.630 Type 1 diabetes mellitus with periodontal disease E10.638 Type 1 diabetes mellitus with other oral complications E10.641 Type 1 diabetes mellitus with with coma E10.649 Type 1 diabetes mellitus with hypoglycemia without coma E10.65 Type 1 diabetes mellitus with E10.69 Type 1 diabetes mellitus with other specified complication E10.8 Type 1 diabetes mellitus with unspecified complications E10.9 Type 1 diabetes mellitus without complications mellitus with hyperosmolarity without non-ketotic hyperglycemic-hyperosmolar E11.00 coma (NKHHC) E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma E11.21 Type 2 diabetes mellitus with diabetic nephropathy E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E11.321 Type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema E11.329 Type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema Type 2 diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular E11.331 edema Type 2 diabetes mellitus with moderate non-proliferative diabetic retinopathy without macular E11.339 edema E11.341 Type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema Type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy without macular E11.349 edema E11.351 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema E11.359 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema E11.36 Type 2 diabetes mellitus with diabetic cataract E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly) neuropathy E11.44 Type 2 diabetes mellitus with diabetic amyotrophy

BMS Provider Manual Page 3 Appendix 535B Effective 4/1/2017

Appendix 535B: Qualifying Diagnosis for Pre-Diabetes, Diabetes, and Obesity

ICD-10 CODE ICD-10-CM DIAGNOSIS CODE DESCRIPTION

E11.49 Type 2 diabetes mellitus with other diabetic neurological complication E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications E11.61 Type 2 diabetes mellitus with diabetic arthropathy E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy E11.618 Type 2 diabetes mellitus with other diabetic arthropathy E11.620 Type 2 diabetes mellitus with diabetic dermatitis E11.621 Type 2 diabetes mellitus with foot ulcer E11.622 Type 2 diabetes mellitus with other skin ulcer E11.628 Type 2 diabetes mellitus with other skin complications E11.630 Type 2 diabetes mellitus with periodontal disease E11.638 Type 2 diabetes mellitus with other oral complications E11.641 Type 2 diabetes mellitus with hypoglycemia with coma E11.649 Type 2 diabetes mellitus with hypoglycemia without coma E11.69 Type 2 diabetes mellitus with other specified complication E11.8 Type 2 diabetes mellitus with unspecified complications E11.9 Type 2 diabetes mellitus without complications E66.01 Morbid (severe) obesity due to excess calories E66.09 Other obesity due to excess calories E66.1 Drug-induced obesity E66.2 Morbid (severe) obesity with alveolar hypoventilation E66.3 Overweight E66.8 Other obesity E66.9 Obesity unspecified Z68.25 Body mass index (BMI) 25.0-25.9, adult Z68.26 Body mass index (BMI) 26.0-26.9, adult Z68.27 Body mass index (BMI) 27.0-27.9, adult Z68.28 Body mass index (BMI) 28.0-28.9, adult Z68.29 Body mass index (BMI) 29.0-29.9, adult Z68.30 Body mass index (BMI) 30.0-30.9, adult Z68.31 Body mass index (BMI) 31.0-31.9, adult Z68.32 Body mass index (BMI) 32.0-32.9, adult Z68.33 Body mass index (BMI) 33.0-33.9, adult Z68.34 Body mass index (BMI) 34.0-34.9, adult Z68.35 Body mass index (BMI) 35.0-35.9, adult Z68.36 Body mass index (BMI) 36.0-36.9, adult Z68.37 Body mass index (BMI) 37.0-37.9, adult Z68.38 Body mass index (BMI) 38.0-38.9, adult Z68.39 Body mass index (BMI) 39.0-39.9, adult

BMS Provider Manual Page 4 Appendix 535B Effective 4/1/2017

Appendix 535B: Qualifying Diagnosis for Pre-Diabetes, Diabetes, and Obesity

Z68.41 Body mass index (BMI) 40.0-44.9, adult

Z68.42 Body mass index (BMI) 45.0-49.9, adult Z68.43 Body mass index (BMI) 50-59.9 , adult Z68.44 Body mass index (BMI) 60.0-69.9, adult Z68.45 Body mass index (BMI) 70 or greater, adult Z68.53 Body mass index (BMI) pediatric 85th percentile to less than 95th percentile for age Z68.54 Body mass index (BMI) pediatric greater than or equal to 95th percentile for age

BMS Provider Manual Page 5 Appendix 535B Effective 4/1/2017