What’s up “with” Diabetic Coding?

Responding to coder questions has always been one of my great joys.  The challenge of searching for the underlying cause or the analysis of a detailed operative note is second only to a Dr. Seuss favorite with my Grands.  Lately, diabetic coding has been a frequent topic for clarification.

According to the American Diabetes Association,“29.1 million Americans have been diagnosed with diabetes with another 86 million identified with pre-diabetes.”  The manifestations and associated conditions are staggering, as this disease impacts many body systems.  In ICD-9-CM code assignment with the designation of primary or secondary whether type I or II, controlled, uncontrolled and with a documented association of manifestations common to diabetes was the guidance. ICD-10-CM implementation eliminated the controlled and uncontrolled designation, opting for a more robust manifestation instruction.

The American Hospital Association (AHA) Coding Clinic publications for first quarter 2016, again second quarter 2016 reiterate the ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 I.A.15 which says:

“With”  the word “with” should be interpreted to mean “associated with” or “due to” when it appears in the code title, the Alphabetic Index, or an instructional note in the Tabular List.  The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List.  These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must like the conditions in order to code them as related. The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.”

As coders plunge into their daily coding process, there remain areas of concern in complying with the instruction that as written seems so clear.  In the setting of a type II diabetic patient presenting with nausea and vomiting, gastric emptying studies support the diagnosis of gastroparesis the diagnosis code assigned would be E11.43.  The proximity of the documentation in the record of the two conditions (diabetes type II) and (Gastroparesis) have no bearing on the expectation to assign one code, assuming the relationship between the diabetes type II and the gastroparesis.

The same is true for CKD, foot ulcer, gangrene, and the list goes on as the coder references the Index “Diabetes, diabetic (Mellitus)(sugar) “with” or enters the key word “diabetes” in the encoder.  Recent coder questions include the diagnosis of cataract.  When the provider has not documented the type of cataract, (nuclear sclerosis, age-related, etc.) the coder is instructed to assume a link between the diabetes and cataract, reporting as diabetic cataract.  This may be an area of concern for some facilities as their statistical analysis will shift from an “H” diagnosis in Chapter 5 diseases of the eye to an “E” diagnosis in Chapter 4 endocrine diseases.  In talking with a local ophthalmologist, this raised awareness for him as he shared he has many diabetic patients that he may perform cataract surgery that have no relationship between the two conditions.  It is important to inform the providers as guidelines change that may impact their patient population data so they understand the need for the appropriate level of specificity documentation.

Osteomyelitis is also causing some eyebrow rising among coders.  The coding book Index, Diabetes “with” includes osteomyelitis “E11.69”.  In the coding book Index, Diabetes Type I or Type II “with” does not include osteomyelitis.  So, what’s a coder to do?  The answer was provided today in the AHIMA October 15, 2016 Conference.  Everywhere in the ICD-10 CM index that “with” is a part of the indexed condition, the link between the condition referenced by the index and the “with” condition is to be made unless the provider has documented the referenced condition is not due to the “with” condition or is due to another condition.  That includes osteomyelitis in a diabetic patient.  Just to be sure we are clear, additional examples including osteomyelitis will be included in the Coding Clinic 4th Quarter 2016.

As we continue to work with providers with regard to their documentation it is important to share with them how their patient is reflected in coding as many of them are unaware of coding guidelines.  Documentation matters now more than ever.


About the Author

Marie Thomas holds a Masters Healthcare Administration from Pfeiffer University, Charlotte, NC, and a Bachelor of Science in Healthcare Administration from Pfeiffer University. Marie has furthered her career education by becoming an AHIMA-Approved ICD-10-CM/PCS Trainer and Ambassador as well as earning the RHIT, CCS, CCDS, and CPC-H credentials. For more information please email us at contact@eclathealth.com