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:
- neuropathic (Charcot’s) arthropathy E11.610
- other diabetic arthropathy E11.618
- peripheral angiopathy without gangrene E11.51
- peripheral angiopathy with gangrene E11.51
- with other circulatory complications E11.59
- cataract E11.36
- glaucoma E11.39
– Use additional code to identify diabetic glaucoma (H40-H42). If unknown, code for unspecified glaucoma (H40.9)
– with macular edema E11.311
– without macular edema E11.319
- with hyperglycemia E11.65
- with hypoglycemia without coma E11.649
- amyotrophy E11.44
- autonomic (poly)neuropathy E11.43
- neuralgia E11.42
- neuropathy E11.40
- periodontal disease E11.630
- other oral complications E11.638
- 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)
- 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
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.