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International Classification of Diseases-10 Coding for Joy Dugan and Jay Shubrook

ore than 29 million Ameri- new codes and did not include a way cans have diabetes. The Cen- to designate laterality. The ICD-10 Mters for Disease Control and system has 68,000 codes that are Prevention predict that the prevalence three to seven digits each and has the of diabetes will increase from 9% to capacity to expand. >30% in the next 35 years. (1) More In general, ICD-10 codes can be than 21 million offices medical visits/ up to seven characters long and are year are scheduled for diabetes. (2) A designed as follows: XXX.XXX.X total of one in five dollars spent on (category.anatomic site/severity.exten- health care in the United States (and sion). The first set of digits before one in three dollars spent through the first decimal point describes the Medicare) are spent on people with general disease or category. The next diabetes. (3) With this in mind, prop- three digits after the first decimal er and accurate coding for diabetes is point describe the etiology, anatom- a necessity. ical site, severity, or clinical detail. The International Classification Finally, some conditions will have a of Diseases 10th Revision—Clinical Modification (ICD-10) is designed second decimal point, followed by a to accurately classify and categorize final digit that may define an initial or all illnesses and diseases seen in the subsequent encounter, the laterality of U.S. health care setting. (4) The cod- a condition, or the number of weeks’ ing system was updated in October gestation (in the case of pregnancy). 2015 to its tenth revision because it This may seem overly detailed, but was thought that the ninth revision it allows for greater specificity of the (ICD-9) no longer accommodated disease and its state. all of the new codes submitted to the Most codes for diabetes will system, and the ICD-9 codes were require four or five digits to provide not descriptive enough to accurately the level of detail required by ICD-10 reflect the state of patients’ diseases. (5). This article provides key updates For example, the ICD-9 system had for ICD-10 coding for diabetes and its Touro University California College of 13,000 three- to five-digit codes. complications. To make sense of the Osteopathic Medicine Primary Care Department, Vallejo, CA This system was not able to take in coding descriptions, the authors will Corresponding author: Jay Shubrook, TABLE 1. Diagnostic Criteria for * and Diabetes [email protected] Normal Prediabetes Diabetes https://doi.org/10.2337/cd16-0052 Fasting glucose (mg/dL) <100 100–125 ≥126 ©2017 by the American Diabetes Association. Readers may use this article as long as the work Random glucose or OGTT (mg/dL) <140 140–199 ≥200 is properly cited, the use is educational and not A1C (%) 5.7 5.7–6.4 6.5 for profit, and the work is not altered. See http:// < ≥ creativecommons.org/licenses/by-nc-nd/3.0 *For prediabetes, use the “abnormal glucose” code R73.09. for details.

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explain them based on the way one TABLE 2. Codes for With Complications might approach diabetes clinically. Code Used to report type 1 diabetes: ICD-10 Codes for Diabetes E10.1X With the presence of For proper coding of diabetes, ICD- 10 codes should reflect the type of di- E10.10 With diabetic ketoacidosis without coma abetes, its current status, and comor- E10.11 With diabetic ketoacidosis with coma bidities of the disease. Compared to E10.2X With renal disease ICD-9, the ICD-10 codes are much E10.21 With more specific. Carefully choosing the E10.22 With diabetic chronic kidney disease most specific ICD-10 codes is import- ant to ensure proper reimbursement. E10.29 With other diabetic kidney E10.3X With eye disease Codes for Screening for Diabetes or Diagnosing E10.311 With ophthalmic complications without macular Prediabetes E10.319 With ophthalmic complications with macular edema Screening for Diabetes: Z13.1 E10.321 With mild nonproliferative with macular edema If a person has risk factors for di- abetes and you want to screen him E10.329 With mild nonproliferative diabetic retinopathy without or her for the condition (via glucose macular edema measurement, oral glucose tolerance E10.331 With macular edema test [OGTT], or A1C test), you E10.339 Without macular edema would use a Z code (which indicates E10.341 With severe nonproliferative diabetic retinopathy with screening or prevention services). macular edema Alternatively, using a code that indi- E10.349 With severe nonproliferative diabetic retinopathy without cates the presence of a risk factor for macular edema diabetes is also acceptable for reim- E10.351 With proliferative diabetic retinopathy with macular bursement. The current acceptable edema risk factors include hypertension E10.359 With proliferative diabetic retinopathy without macular (I10) and obesity (E66.XX). edema Prediabetes Diagnosis: R73.09 E10.36 With diabetic cataract If a person has prediabetes, the rec- E10.39 With other diabetic ophthalmic complication ommended ICD-10 code for abnor- E10.4X With nerve disease mal glucose is R73.09, but this code also covers abnormal fasting glucose, E10.40 With , unspecified abnormal glucose tolerance, or an el- E10.41 With diabetic mononeuropathy evated A1C in the prediabetes range E10.42 With diabetic polyneuropathy (Table 1). E10.43 With diabetic autonomic (poly)neuropathy Codes for Known Diabetes E10.44 With diabetic amyotrophy When you are treating a person who E10.49 With other diabetic neurological complication has known diabetes, the first level of distinction is the type of diabetes. E10.5X With peripheral vascular disease Under ICD-9, the main types of dia- E10.51 With diabetic peripheral angiopathy without gangrene betes were coded 250.XX. To properly E10.52 With diabetic peripheral angiopathy with gangrene code for diabetes under ICD-10, four E10.59 With other circulatory complications to five digits are needed. The follow- ing steps will help to ensure accurate E10.6X With diabetes-related musculoskeletal, oral, or skin complications; ; or diabetes coding: E10.61 With diabetic Step 1. Confirm the Type of E10.610 With diabetic neuropathic arthropathy Diabetes The current codes for common forms E10.618 With other diabetic arthropathy of diabetes are: E10.620 With diabetic dermatitis • Type 1 diabetes: E10.XXX E10.621 With foot • : E11.XXX TABLE CONTINUED ON P. 3 →

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TABLE 2. Codes for Type 1 Diabetes With Complications, • mellitus (GDM): O24.429. TABLE 2. Codes forcontinued Type 1 Diabetes from p. With2 Complications Code Used to report type 1 diabetes: There are a number of special cate- E10.622 With other skin ulcer gories of diabetes that have a different pathogenesis from what is known for E10.628 With other skin complications type 1 and type 2 diabetes. These are E10.630 With periodontal disease collectively called “secondary diabe- E10.638 With other oral complications tes” and should not be confused with E10.641 With hypoglycemia with coma type 2 diabetes. For secondary diabe- tes, use the following codes: E10.649 With hypoglycemia without coma or with hypoglycemia unawareness • E08.XXX: “Diabetes due to under- lying condition” is for diabetes E10.65 With hyperglycemia caused by diseases such as can- E10.69 With other specified complication cer, pancreatitis, or nutritional E10.8 With complications, unspecified deficiencies. E10.9 Without complications • E09.XXX: “Drug- or chemical- induced diabetes mellitus” is for TABLE 3. Codes for Type 2 Diabetes With Complications diabetes induced by a drug or toxin. Code Used to report type 2 diabetes with: • E13.XXX: “Other specified diabe- E11.0X With hyperosmolarity tes mellitus” is for genetic defects of E11.0 0 Without nonketotic hyperglycemic hyperosmolar coma β-cell function and action E11.01 With nonketotic hyperglycemic hyperosmolar coma or post-pancreatectomy diabetes. E11.2X With kidney complications Step 2. Describe Whether the E11.21 With diabetic nephropathy Person’s Diabetes Is Currently Well Controlled E11.22 With diabetic chronic kidney disease Level of control is indicated by the E11.29 With other diabetic kidney complications number after the decimal point. If a E11.3X With eye complications person’s diabetes is well controlled, E11.31 With diabetic retinopathy, unspecified that digit will be 9 (i.e., EXX.9). For E11.311 With diabetic retinopathy with macular edema example, a person with type 2 dia- betes that is well controlled who has E11.319 With diabetic retinopathy without macular edema no complications would be indicated E11.32 With mild nonproliferative diabetic retinopathy` by the code E11.9. Likewise, a per- E11.321 With mild nonproliferative diabetic retinopathy with macular son with type 1 diabetes that is well edema controlled who has no complications E11.329 With mild nonproliferative diabetic retinopathy without would be indicated by the code E10.9. macular edema It is important to remember E11.33 With moderate nonproliferative diabetic retinopathy that E11.9 actually describes only a E11.331 With moderate nonproliferative diabetic retinopathy with minority of people with type 2 diabe- macular edema tes. One of the goals of ICD-10 is to better characterize the control of peo- E11.339 With moderate nonproliferative diabetic retinopathy without macular edema ple with diabetes and the specifics of the complications that they are expe- E11.34 With severe nonproliferative diabetic retinopathy riencing. However, many patients E11.341 With severe nonproliferative diabetic retinopathy with with diabetes have hyperglycemia, macular edema which is considered a complication. E11.349 With severe nonproliferative diabetic retinopathy without Therefore, a diagnosis code with a macular edema complication code is appropriate for E11.36 With diabetic cataract the majority of people with diabetes. E11.39 With other diabetic ophthalmic complication All of the digits beyond the dec- imal point are the same regardless TABLE CONTINUED ON P. 4 → of the type of diabetes (e.g., type 1 vs. type 2 diabetes). Each numerical

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TABLE 3. Codes for Type 2 Diabetes With Complications, code after the decimal point (numbers 1–8) describes a different complica- TABLE 3. Codes forcontinued Type 2 Diabetes from p. With3 Complications tion. The second and third digit after E11.4X With nerve complications the decimal point subcategorize that E11.40 With diabetic neuropathy, unspecified complication. For example, the most E11.41 With mononeuropathy common code used for type 2 diabe- tes is E11.65 (type 2 diabetes mellitus E11.42 With diabetic polyneuropathy with hyperglycemia), which reflects E11.45 With autonomic neuropathy (e.g., gastroparesis) suboptimal control. The most com- E11.49 With other diabetic neurological complications mon codes for type 1 diabetes are E11.5X With peripheral vascular disease E10.65 (type 1 diabetes with hypergly- cemia) and E10.649 (type 1 diabetes E11.51 With diabetic peripheral angiopathy without gangrene with hypoglycemia without coma). E11.52 With diabetic peripheral angiopathy with gangrene Step 3. For Diabetes That Is E11.59 With other circulatory complications Not Well Controlled, Identify E11.6X With diabetes-related musculoskeletal, oral, or skin Any Complications complications; hypoglycemia; or hyperglycemia The first digit after the decimal point E11.61 With diabetic arthropathy describes both the level of metabolic E11.610 With diabetic neuropathic arthropathy control and the presence of complica- E11.618 With other diabetic arthropathy tions. Further digits subcategorize the E11.62 With skin complications complications. As mentioned above, the number 9 after the decimal point E11.620 With diabetic dermatitis (i.e., E10.9 or E11.9) both defines E11.621 With foot ulcer the diabetes as controlled (i.e., with- E11.622 With other skin ulcer out hyperglycemia or hypoglycemia) E11.628 With other skin complications and documents the absence of com- plications. Thus, using a 9 after the E11.63 With oral complications decimal point should be the excep- E11.630 With periodontal disease tion rather than the rule, given that E11.638 With other oral complications most people with diabetes have either E11.64 With hypoglycemia suboptimal control, complications, or both. The following codes pertain to E11.641 With hypoglycemia with coma complications of type 2 diabetes: Ell.649 Without hypoglycemia without coma • Severe hyperosmolarity: E11.0X E11.65 With hyperglycemia • Kidney complications: E11.2X E11.69 With other complications • Eye complications: E11.3X • Nerve complications: E11.4X E11.8X With other non-specified complication • Peripheral vascular disease: E11.5X E11.9X Well controlled without hyperglycemia, hypoglycemia, • Other specified complications, or complications including musculoskeletal, oral, and skin complications; hypogly- TABLE 4. Codes for Secondary Diagnosis for Diseases cemia; and hyperglycemia: E11.6X Associated With Diabetes • Other nonspecified complications: Code Used to report: E11.8X Dermatology • Well-controlled type 2 diabetes S81.801 Open wound, unspecified, right lower leg without hyperglycemia, hypogly- cemia, or complications: E11.9X L97. X– Site of ulceration L98.X More detailed codes further subcate- L97.411 Non-pressure chronic ulcer of right heel and mid-foot limited gorize complications. Table 2 provides to breakdown of skin ICD-10 codes for complications as- L97.5 Non-pressure chronic ulcer of other part of the foot sociated with type 1 diabetes; table 3 L97.533 Non-pressure chronic ulcer of other part of left foot with lists codes for complications associat- necrosis of muscle ed with type 2 diabetes. TABLE CONTINUED ON P. 5 →

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Step 4. Describe Any Identified TABLE 4. Codes for Secondary Diagnosis for Diseases Complication AssociatedAssociated With Diabetes, With continuedDiabetes from p. 4 This means you will use a primary Nephrology diabetes code that describes the type N18.1 Chronic kidney disease (CKD) stage I of diabetes, then specify whether it N18.2 CKD stage II is controlled and whether there is a N18.3 CKD stage III complication, and then add a second code specific to that complication. N18.4 CKD stage IV Sample codes for complications of N18.5 CKD stage V diabetes are shown in Table 4; codes N18.6 End-stage renal disease for common comorbidities are shown R80.9 Microalbuminuria in Table 5). Z99.2 Dependence on renal dialysis Example 1 E10.42 Presence of AV shunt for dialysis A patient has type 2 diabetes with Hypoglycemia polyneuropathy, hypertension with albuminuria, and dyslipidemia. The E10.649 Type 1 diabetes with hypoglycemia without coma coding to document this patient E11.649 Type 2 diabetes with hypoglycemia without coma should be E11.65 (type 2 diabetes E08.64 Diabetes due to underlying condition with hypoglycemia with hyperglycemia), E11.42 (type E09.64 Drug- or chemical-induced diabetes with hypoglycemia 2 diabetes with polyneuropathy), E16.0 Drug-induced hypoglycemia without coma I10 (hypertension), R80.9 (micro- albuminuria), and E78.2 (mixed E16.1 Other hypoglycemia hyperlipidemia). E16.2 Hypoglycemia, unspecified Example 2 EXX.641 Fill in with code for type of diabetes with hypoglycemia and coma A patient with type 1 diabetes has an active foot ulcer on the bottom of TABLE 5. Codes for Common Comorbid Disease Conditions his right foot. The coding to docu- ment this patient should be E10.621 Code Used to report: (type 1 diabetes with foot ulcer) and F17. 210 Nicotine dependence, cigarettes, uncomplicated L97.411 (non-pressure chronic ulcer K31.84 Gastroparesis of right heel and mid-foot limited to I10 Essential hypertension breakdown of skin). Comorbid conditions affect the Hyperlipidemia: complexity of care and the treatments E78.0 Pure hypercholesterolemia you choose and thus should be coded E78.1 Pure hypertriglyceridemia as diagnoses. One nice feature of the E78.2 Mixed hyperlipidemia BMI coding shown in Table 5 is that E78.5 Hyperlipidemia, unspecified all BMI codes start with Z68, and the digits after the decimal are the actual Hypothyroidism: BMI rounded down to the whole E06.3 Due to Hashimoto’s disease number. In the authors’ experience, E89.0 Postoperative or postablative coding obesity to the level of the BMI E03.9 Acquired has improved the ability to get cover- age for additional medications. This Z13.29 Thyroid disorder screen suggests that some insurers may be R94.6 Abnormal thyroid or screen relying on the coding to make cover- E66.0 Obesity due to excess calories age decisions. E66.01 Morbid severe obesity due to excess calories Codes to Document E66.9 Obesity, unspecified Complexity of Care Provided Also utilize a Z68 code with obesity for BMI: Finally, there are codes that demon- Z68.30 BMI 30.0–30.9 kg/m2 strate the additional work you do or

2 the additional complexity of the care Z68.31 BMI 31.0–31.9 kg/m you are providing. These codes help TABLE CONTINUED ON P. 6 → to justify this higher level of care.

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TABLE 5. Codes for Common Comorbid Disease Conditions, • Did you provide dietary or exer- continued from p. 5 cise counseling? These are noted TABLE 5. Codes for Common Comorbid Disease Conditions with an additional Z code: Code Used to report: ❍❍ Dietary counseling and surveil- Z68.32 BMI 32.0–32.9 kg/m2 lance: Z71.3 ❍❍ Z68.33 BMI 33.0–33.9 kg/m2 Exercise counseling: Z71.89 • Is the patient using insulin? Note 2 Z68.34 BMI 34.0–34.9 kg/m that the “long-term use” code Z68.35 BMI 35.0–35.9 kg/m2 Z79.4 code can be used once Z68.36 BMI 36.0–36.9 kg/m2 the drug has been initiated for Z68.37 BMI 37.0 – 37.9 kg /m 2 any person who is taking insulin

2 chronically Z68.38 BMI 38.0–38.9 kg/m • Is the patient on an insulin Z68.39 BMI 39.0 –39.9 kg/m2 pump? Codes related to pump Z68.41 BMI 40.0–44.9 kg/m2 use include: Z68.42 BMI 45.0–49.9 kg/m2 ❍❍ : Z96.41 ❍❍ Counseling, titration, removal, Z68.43 BMI 50.0–59.9 kg/m2 training, or fitting/adjustment Z68.44 BMI 60.0–69.9 kg/m2 of insulin pump: Z46.81 Z68.45 BMI >70.0 kg/m2 ❍❍ Insulin pump complications: G47.33 Obstructive sleep apnea T85.694 • Has the patient underdosed or E28.2 Polycystic ovarian syndrome overdosed insulin? Codes related BOX 1. Case Studies for Diabetes Coding to these situations include: ❍❍ Underdosing of insulin: T38.3X6 Case 1: ❍❍ The patient is a 45-year-old man who has had type 1 diabetes for 25 years. Unintentional overdosing of At today’s visit, he is diagnosed with gastroparesis. He reports one hypo- insulin: T38.3X1 glycemic episode with a random glucose of 43 mg/dL. His A1C is 7.4%. The ❍❍ Suspected self-harm by over- patient has a history of nonproliferative retinopathy and CKD stage 1. You dosing insulin: T38.3X2X provide dietary counseling during the visit. What codes would you use? Answer: After these T codes, there should be a • E10.65: Type 1 diabetes with hyperlgycemia modifier at the end to denote initial encounter (A), subsequent encounter • E10.43: Type 1 diabetes with gastroparesis (autonomic neuropathy) (D), or Sequalae (S). For example, an • E10.329: Type 1 diabetes with nonproliferative retinopathy initial encounter for intentional self- • E10.649: Type 1 diabetes with hypoglycemia harm by overdosing insulin should be • E10.22: Type 1 diabetes with CKD stage 1 “T38.3X2A”. • K31.84: Gastroparesis Codes for Pregnancy in • Z71.3: Dietary counseling Diabetes • Z79.4: Insulin use Codes to report pregnancy in women with diabetes include: Case 2: The patient is a 53-year-old obese man (BMI 37 kg/m2) who has uncontrolled • Preexisting type 1 diabetes in type 2 diabetes with A1C of 8.8%, CKD stage 3, controlled hypertension on pregnancy: O24.01 an ACE inhibitor, and mixed hyperlipidemia. He is takes daily insulin injec- • Preexisting type 2 diabetes in tions. What codes would you use? pregnancy: O24.11 Answer: • GDM, diet controlled: O24.410 • E11.65: Type 2 diabetes with hyperglycemia • GDM, insulin controlled: O24.414 • Obesity complicating pregnancy, • E11.22: Type 2 diabetes with CKD unspecified: O99.210 • N18.3: CKD stage 3 Conclusion • E78.2: Mixed hyperlipidemia Remember the following steps when • I10: Essential hypertension coding for patients with diabetes: • Z79.4: Insulin use 1. Document the type of diabetes • Z68.37: Obesity they have.

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conflicts of interest relevant to this article BOX 2. Tools to Help Providers With ICD-10 Coding were reported.

• In many electronic health record systems, providers can type in a References description of a condition in words and receive a list of codes from 1.Centers for Disease Control and which to choose. Some systems allow providers to type in an outdated Prevention. National data. Available from ICD-9 code and then provide the corresponding current ICD-10 code. http://www.cdc.gov/diabetes/data/national. • There are a number of online tools that can help with coding. Among html. Accessed 7 July 2016 them are: 2.Centers for Disease Control and Prevention. Annual number and percent ❍❍ Centers for Medicare & Medicaid Services websites: https://www. distribution of ambulatory care visits by cms.gov/medicare/coding/icd10/2015-icd-10-cm-and-gems.html setting type according to diagnosis group. and https://www.cms.gov/medicare/coding/icd10/providerre United States, 2009–2010. Available from sources.html http://www.cdc.gov/nchs/data/ahcd/com- bined_tables/AMC_2009-2010_combined ❍❍ The ICD-10 website: https://www.ICD10data.com _web_table01.pdf. Accessed 7 July 2016 3.American Diabetes Association. 2. Document if their diabetes is con- Box 1 offers two case studies to help Economic Costs of Diabetes in the U.S. in trolled without any complications. you apply your knowledge of diabetes 2012. Diabetes Care 2013;36:1033–1046 3. If their diabetes is uncontrolled or coding. Box 2 provides information 4.ICD10data.com. About ICD10data.com. about additional tools to help provid- Available from http://www.icd10data.com/ they have any complications, doc- About. Accessed 7 July 2016 ument the complications using the ers with ICD-10 coding. 5.Hodorowicz MA. New ICD-10-CM cod- codes that fall to the right of the ing system: a review of the basics. AADE in decimal point. Duality of Interest Practice 2016;4:12–15 4. Add the secondary diagnosis code Jay Shubrook serves as an associate editor to support the diabetes code. for Clinical Diabetes. No other potential

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