HCC Coding for Providers – Type 2 Diabetes with Complications

Type 2 Diabetes is frequently coded as uncomplicated when in fact complications are present.

According to the CMS Participant Guide, “Physicians should document and code all conditions that co-exist at the time of the encounter/visit that require or affect patient treatment or management.”

All complications should be documented as specifically as possible. ICD-10 allows for assumed causal relationships with many of the chronic complications.

When coding complications for Type 2 DM use E11.9 with diabetic:

Arthropathy:

  • neuropathic (Charcot’s) arthropathy E11.610
  • other diabetic arthropathy E11.618

Circulatory complications:

  • peripheral angiopathy without gangrene E11.51
  • peripheral angiopathy with gangrene E11.51
  • with other circulatory complications E11.59

Eye complications:

  • cataract E11.36
  • glaucoma E11.39
     – Use additional code to identify diabetic glaucoma (H40-H42). If unknown, code for unspecified glaucoma (H40.9)
  • retinopathy
    – with macular edema E11.311
    – without macular edema E11.319

Hyperglycemia/Hypoglycemia:

  • with hyperglycemia E11.65
  • with hypoglycemia without coma E11.649

Neurological complications:

  • amyotrophy E11.44
  • autonomic (poly)neuropathy E11.43
  • neuralgia E11.42
  • neuropathy E11.40

Oral complications:

  • periodontal disease E11.630
  • other oral complications E11.638

Skin Complications:

  • dermatitis E11.620
  • foot ulcer E11.621
    – Use additional code to identify the site of the ulcer (L97.4* – L97.5*)
  • other skin ulcer E11.622 Use additional code to identify the site of the ulcer (L97.4* – L97.5*) or (L98.41* – L98.49)
Other Specified Complication (MUST LINK THIS TO THE SPECIFIC COMPLICATION, OTHERWISE FAILS AN AUDIT)

  • erectile dysfunction E11.69
     – Use additional code to identify ED – N52.9
  • hyperlipidemia E11.69
    – Use additional code to specify hyperlipidemia. If unknown, code for unspecified hyperlipidemia E78.5

*most common missed complications, not an all-inclusive list

Sources:

1. 2008 Risk Adjustment Data Technical Assistance For Medicare Advantage Organizations Participant Guide 6.4.1 Co-existing and Related Conditions.

2. AHA Coding Clinic: First Quarter 2016, Page 11 and Second Quarter 2016, Page 36.