Diabetes; IT Is Complicated

According to CMS, 26% of fee-for-service Medicare beneficiaries had diabetes in 2022, with higher prevalence in these demographic groups: 

• American Indian/Alaska Native 
• Black/African American 
• Latino/Hispanic 
• Men 
• Dual-eligible beneficiaries

It’s easy to think that such a common condition means that clinical documentation is simple and straightforward, but we can see incomplete or conflicting diabetes documentation in our quality reviews. Why? Because there are different types of diabetes, with and without complications. Providers need to remember to tell the full story in their documentation. When recognizing the presence and severity of a chronic condition such as diabetes, it is important to “think in ink” and provide a complete and accurate assessment with a plan of care.

What’s the most common coding omission with diabetes? 

There are three areas many providers often leave out in their diabetes documentation: 

1. Classifying the correct type of diabetes
2. Explaining diabetes with complications
3. Clarifying whether the diabetes is controlled or uncontrolled 

Classifying the right type of diabetes 

There are multiple types of diabetes caused by different reasons, which is why it’s important to include this in the documentation. This will ensure that the correct ICD 10-CM diagnosis code is reported.

Use this as an easy reference: 

• E08 is for secondary diabetes caused by Cushing’s, pancreatitis, pancreatic cancer, cystic fibrosis, etc. 
• E09 is for secondary diabetes induced by a drug or chemical. 
• E10 is for type I diabetes caused by an autoimmune process. 
• E11 is type II diabetes due to a shortage of insulin or insulin resistance. 
• E13 is for other specified diabetes due to a genetic defect, type 1.5 or pancreatectomy. 

Getting complications right 

You need to be sure it’s clear if your patient has complications associated with diabetes. Diabetes can affect the whole-body system: 

• Circulatory 
• Renal 
• Neurological
• Ophthalmic
• Integumentary
• Digestive
• Musculoskeletal

Because of that, a patient can have additional complications that include, but are not limited to: 

• Peripheral angiopathy 
• Polyneuropathy 
• Retinopathy 
• Nephropathy 
• Chronic kidney disease (CKD) 
• End-stage renal disease 
• Diabetic foot ulcers 
• Gastroparesis 
• Periodontal disease

Document a clear relationship between diabetes and the associated complication. This will tell the most complete and accurate story.

What’s the difference between E11.8 and E11.69? 

E11.8 explains type II diabetes with unspecified complications whereas E11.69 is for a patient who has type II diabetes mellitus with other specified complications. 

Here are some pro tips: 

• E11.8: Type II diabetes mellitus with unspecified complications
  • Be as accurate and specific as possible to describe the diabetic complication with the status (controlled, uncontrolled hyperglycemia or uncontrolled hypoglycemia) and plan of care. 
  • If there is not documentation to support a diabetic complication, do not use E11.8.
• E11.69: Type 11 diabetes mellitus with other specified complication
  • Your documentation must show a cause-and-effect relationship with the diabetes and the identified specified complication. 
  • That specified complication must be reported with a separate ICD-10-CM code.

Clarifying whether the diabetes is controlled or uncontrolled

A1c measures the blood sugar levels in a patient’s blood. It’s important to explain if a patient’s diabetes is controlled or uncontrolled and, if uncontrolled, how in coding. 

• Controlled diabetes means a patient’s A1c is between 6.5–7% or lower. 
• Uncontrolled diabetes is when the body can’t regulate blood-sugar levels: 
• Hyperglycemia is when a patient’s blood sugar is too high and is above 7%. 
• Hypoglycemia is when a patient’s blood sugar is too low and blood glucose levels fall below 70 mg/dl. 

Be sure to specify if the patient’s diabetes is controlled or uncontrolled. If uncontrolled, please document specifically hyperglycemia or hypoglycemia.

Documenting medication management 

You’ll also want to explain which treatment regimen the patient is on: 

• Oral antidiabetic drugs 
• Insulin 
• Other injectables (e.g., Wegovy) 

Putting it all together: documentation best practices 

Clinical Documentation that is clear, consistent and concise will ensure the accurate and specific diagnosis code reporting for diabetes.

1. Always provide an assessment and plan of care. 
2. Document all comorbidities, complications and manifestations present at the time of the encounter that impact patient care. 
3. Explain the cause and the effect of diabetes (what it is due to, with its associated with, if it is secondary, etc.). 

Here are a few examples: 

• Type II diabetes, on insulin, uncontrolled with hyperglycemia. 
  • Recent A1C on 3/3/24 is 11.5, will increase Lantus and refer to diabetes education for follow up in 6 weeks. 
• Secondary diabetes, controlled, with polyneuropathy. 
  • Continues Gabapentin with slight improvement in sensation to the lower extremities.   
• Diabetic peripheral angiopathy. 
  • Continues to have intermittent claudication, recommend vascular consult, continue Cilostazol. 
• Diabetic foot ulcer. 
  • Left heel dressing is intact with no drainage noted, continue wound care for area of skin breakdown, continue current medications. 

The bottom line

Specificity in documenting diabetes correctly ensures that all appropriate diagnosis codes, including complication codes, are reported. This accurately reflects the severity of the patient’s disease burden and their illness.  

Accurate and specific documentation is essential for accurate ICD 10-CM diagnosis code reporting, and this will ensure the appropriate reimbursement. ICD 10-CM diagnosis codes are how patient diagnoses are reported to the CMS and are essential to painting a complete picture of a patient’s status and their treatment.