How to properly code diabetes complexity

Q: We have a large patient population with diabetes, and we are still struggling with how to code each of the manifestations. Can you give us a good guideline to help with our coding?

A: The coding guideline “with” has caused some confusion even among coding professionals, so I understand why you are having a difficult time. An area that contains many instances of using this guideline in ICD-10-CM is coding diabetes mellitus with associated conditions.

There are 53 instances of “with” subterm conditions listed under the main term diabetes. To add to the complexity of coding this condition, there are coding guidelines for the term “with” in ICD-10 that were not in ICD-9.

Section I.A.15 of the ICD-10-CM Official Guidelines for Coding and Reporting states the following:

The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List.

The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.

There was a recent clarification regarding this guideline published in the first quarter 2016 issue of AHA Coding Clinic on page 11. According to this clarification, the subterm “with” in the index should be interpreted as a link between diabetes and any of those conditions indented under the word “with.” 

As we look to the main term diabetes in the ICD-10-CM Codebook Index, any of the conditions under the subterm “with” (i.e., gangrene, neuropathy, hyperglycemia, etc.) can be coded without the physician’s documentation specifically stating that these conditions are linked. The cause-and-effect relationship is assumed between diabetes and certain diseases of the kidneys, nerves and circulatory system because they are listed specifically under the subterm “with.”

For instance, to accurately assign the code E11.319 (Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema), the physician/provider documentation does not need to show a link between the diagnoses of diabetes and retinopathy.  

This sounds easy enough but it can be confusing figuring out how to interpret this guideline, especially because it is so new with ICD-10.

It’s important to remember that if the physician or provider’s documentation specifically states that the diabetes isn’t the underlying cause of the other condition, the condition should not be coded as a diabetic complication. So before you choose diagnosis code(s), be sure to review the entire record. With this in mind, the entire record needs to be reviewed.If it’s unclear whether or not the two conditions are related, you should query the provider.