Icd 10 for insulin dependent type 2 diabetes

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More than 29 million Americans have diabetes. The Centers for Disease Control and Prevention predict that the prevalence of diabetes will increase from 9% to >30% in the next 35 years (1). More than 21 million medical office visits for diabetes are scheduled each year (2). A total of one in five dollars spent on health care in the United States (and one in three dollars spent through Medicare) are spent on people with diabetes (3). With this in mind, proper and accurate coding for diabetes is a necessity.

The International Classification of Diseases, 10th Revision—Clinical Modification (ICD-10) is designed to accurately classify and categorize all illnesses and diseases seen in the U.S. health care setting. (4) The coding system was updated in October 2015 to its 10th revision because it was thought that the 9th revision (ICD-9) no longer accommodated all of the new codes submitted to the system, and the ICD-9 codes were not descriptive enough to accurately reflect the state of patients’ diseases. For example, the ICD-9 system had 13,000 three- to five-digit codes. This system was not able to take in new codes and did not include a way to designate laterality. The ICD-10 system has 68,000 codes that are three to seven digits each and has the capacity to expand.

In general, ICD-10 codes can be up to seven characters long and are designed as follows: XXX.XXX.X (category.anatomic site/severity.extension). The first set of digits before the first decimal point describes the general disease or category. The next three digits after the first decimal point describe the etiology, anatomical site, severity, or clinical detail. Finally, some conditions will have a second decimal point, followed by a final digit that may define an initial or subsequent encounter, the laterality of a condition, or the number of weeks’ gestation (in the case of pregnancy). This may seem overly detailed, but it allows for greater specificity of the disease and its state.

Most codes for diabetes will require four or five digits to provide the level of detail required by ICD-10 (5). This article provides key updates for ICD-10 coding for diabetes and its complications. To make sense of the coding descriptions, the authors will explain them based on the way one might approach diabetes clinically.

ICD-10 Codes for Diabetes

For proper coding of diabetes, ICD-10 codes should reflect the type of diabetes, its current status, and comorbidities of the disease. Compared to ICD-9, the ICD-10 codes are much more specific. Carefully choosing the most specific ICD-10 codes is important to ensure proper reimbursement.

Codes for Screening for Diabetes or Diagnosing Prediabetes

Screening for Diabetes: Z13.1

If a person has risk factors for diabetes and you want to screen him or her for the condition (via glucose measurement, oral glucose tolerance test [OGTT], or A1C test), you would use a Z code (which indicates screening or prevention services). Alternatively, using a code that indicates the presence of a risk factor for diabetes is also acceptable for reimbursement. The current acceptable risk factors include hypertension (I10) and obesity (E66.XX).

Prediabetes Diagnosis: R73.09

If a person has prediabetes, the recommended ICD-10 code for abnormal glucose is R73.09, but this code also covers abnormal fasting glucose, abnormal glucose tolerance, or an elevated A1C in the prediabetes range (Table 1).

TABLE 1.

Diagnostic Criteria for Prediabetes* and Diabetes

NormalPrediabetesDiabetesFasting glucose (mg/dL)<100100–125≥126Random glucose or OGTT (mg/dL)<140140–199≥200A1C (%)<5.75.7–6.4≥6.5

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*For prediabetes, use the “abnormal glucose” code R73.09.

Codes for Known Diabetes

When you are treating a person who has known diabetes, the first level of distinction is the type of diabetes. Under ICD-9, the main types of diabetes were coded 250.XX. To properly code for diabetes under ICD-10, four to five digits are needed. The following steps will help to ensure accurate diabetes coding.

Step 1. Confirm the Type of Diabetes

The current codes for common forms of diabetes are:

• Type 1 diabetes: E10.XXX

• Type 2 diabetes: E11.XXX

• Gestational diabetes mellitus (GDM): O24.429

There are a number of special categories of diabetes that have a different pathogenesis from what is known for type 1 and type 2 diabetes. These are collectively called “secondary diabetes” and should not be confused with type 2 diabetes. For secondary diabetes, use the following codes:

• E08.XXX: “Diabetes due to underlying condition” is for diabetes caused by diseases such as cancer, pancreatitis, or nutritional deficiencies.

• E09.XXX: “Drug- or chemical-induced diabetes mellitus” is for diabetes induced by a drug or toxin.

• E13.XXX: “Other specified diabetes mellitus” is for genetic defects of β-cell function and insulin action or post-pancreatectomy diabetes.

Step 2. Describe Whether the Person’s Diabetes Is Currently Well Controlled

Level of control is indicated by the number after the decimal point. If a person’s diabetes is well controlled, that digit will be 9 (i.e., EXX.9). For example, a person with type 2 diabetes that is well controlled who has no complications would be indicated by the code E11.9. Likewise, a person with type 1 diabetes that is well controlled who has no complications would be indicated by the code E10.9.

It is important to remember that E11.9 actually describes only a minority of people with type 2 diabetes. One of the goals of ICD-10 is to better characterize the control of people with diabetes and the specifics of the complications that they are experiencing. However, many patients with diabetes have hyperglycemia, which is considered a complication. Therefore, a diagnosis code with a complication code is appropriate for the majority of people with diabetes.

All of the digits beyond the decimal point are the same regardless of the type of diabetes (e.g., type 1 vs. type 2 diabetes). Each numerical code after the decimal point (numbers 1–8) describes a different complication. The second and third digit after the decimal point subcategorize that complication. For example, the most common code used for type 2 diabetes is E11.65 (type 2 diabetes with hyperglycemia), which reflects suboptimal control. The most common codes for type 1 diabetes are E10.65 (type 1 diabetes with hyperglycemia) and E10.649 (type 1 diabetes with hypoglycemia without coma).

Step 3. For Diabetes That Is Not Well Controlled, Identify Any Complications

The first digit after the decimal point describes both the level of metabolic control and the presence of complications. Further digits subcategorize the complications. As mentioned above, the number 9 after the decimal point (i.e., E10.9 or E11.9) both defines the diabetes as controlled (i.e., without hyperglycemia or hypoglycemia) and documents the absence of complications. Thus, using a 9 after the decimal point should be the exception rather than the rule, given that most people with diabetes have either suboptimal control, complications, or both. The following codes pertain to complications of type 2 diabetes:

• Severe hyperosmolarity: E11.0X

• Kidney complications: E11.2X

• Eye complications: E11.3X

• Nerve complications: E11.4X

• Peripheral vascular disease: E11.5X

• Other specified complications, including musculoskeletal, oral, and skin complications; hypoglycemia; and hyperglycemia: E11.6X

• Other unspecified complications: E11.8X

• Well-controlled type 2 diabetes without hyperglycemia, hypoglycemia, or complications: E11.9X

More detailed codes further subcategorize complications. Table 2 provides ICD-10 codes for complications associated with type 1 diabetes; Table 3 lists codes for complications associated with type 2 diabetes.

TABLE 2.

Codes for Type 1 Diabetes With Complications

CodeUsed to report type 1 diabetes:E10.1XWith the presence of diabetic ketoacidosis E10.10With diabetic ketoacidosis without coma E10.11With diabetic ketoacidosis with comaE10.2XWith renal disease E10.21With diabetic nephropathy E10.22With diabetic chronic kidney disease E10.29With other diabetic kidneyE10.3XWith eye disease E10.311With ophthalmic complications without macular edema E10.319With ophthalmic complications with macular edema E10.321With mild nonproliferative diabetic retinopathy with macular edema E10.329With mild nonproliferative diabetic retinopathy without macular edema E10.331With macular edema E10.339Without macular edema E10.341With severe nonproliferative diabetic retinopathy with macular edema E10.349With severe nonproliferative diabetic retinopathy without macular edema E10.351With proliferative diabetic retinopathy with macular edema E10.359With proliferative diabetic retinopathy without macular edema E10.36With diabetic cataract E10.39With other diabetic ophthalmic complicationE10.4XWith nerve disease E10.40With diabetic neuropathy, unspecified E10.41With diabetic mononeuropathy E10.42With diabetic polyneuropathy E10.43With diabetic autonomic (poly)neuropathy E10.44With diabetic amyotrophy E10.49With other diabetic neurological complicationE10.5XWith peripheral vascular disease E10.51With diabetic peripheral angiopathy without gangrene E10.52With diabetic peripheral angiopathy with gangrene E10.59With other circulatory complicationsE10.6XWith diabetes-related musculoskeletal, oral, or skin complications; hypoglycemia; or hyperglycemia E10.61With diabetic arthropathy E10.610With diabetic neuropathic arthropathy E10.618With other diabetic arthropathy E10.620With diabetic dermatitis E10.621With foot ulcer E10.622With other skin ulcer E10.628With other skin complications E10.630With periodontal disease E10.638With other oral complications E10.641With hypoglycemia with coma E10.649With hypoglycemia without coma or with hypoglycemia unawareness E10.65With hyperglycemia E10.69With other specified complicationE10.8With complications, unspecifiedE10.9Without complications

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TABLE 3.

Codes for Type 2 Diabetes With Complications

CodeUsed to report type 2 diabetes with:E11.0XWith hyperosmolarity E11.00Without nonketotic hyperglycemic hyperosmolar coma E11.01With nonketotic hyperglycemic hyperosmolar comaE11.2XWith kidney complications E11.21With diabetic nephropathy E11.22With diabetic chronic kidney disease E11.29With other diabetic kidney complicationsE11.3XWith eye complications E11.31With diabetic retinopathy, unspecified E11.311With diabetic retinopathy with macular edema E11.319With diabetic retinopathy without macular edema E11.32With mild nonproliferative diabetic retinopathy` E11.321With mild nonproliferative diabetic retinopathy with macular edema E11.329With mild nonproliferative diabetic retinopathy without macular edema E11.33With moderate nonproliferative diabetic retinopathy E11.331With moderate nonproliferative diabetic retinopathy with macular edema E11.339With moderate nonproliferative diabetic retinopathy without macular edema E11.34With severe nonproliferative diabetic retinopathy E11.341With severe nonproliferative diabetic retinopathy with macular edema E11.349With severe nonproliferative diabetic retinopathy without macular edema E11.36With diabetic cataract E11.39With other diabetic ophthalmic complicationE11.4XWith nerve complications E11.40With diabetic neuropathy, unspecified E11.41With mononeuropathy E11.42With diabetic polyneuropathy E11.45With autonomic neuropathy (e.g., gastroparesis) E11.49With other diabetic neurological complicationsE11.5XWith peripheral vascular disease E11.51With diabetic peripheral angiopathy without gangrene E11.52With diabetic peripheral angiopathy with gangrene E11.59With other circulatory complications E11.6XWith diabetes-related musculoskeletal, oral, or skin complications; hypoglycemia; or hyperglycemia E11.61With diabetic arthropathy E11.610With diabetic neuropathic arthropathy E11.618With other diabetic arthropathy E11.62With skin complications E11.620With diabetic dermatitis E11.621With foot ulcer E11.622With other skin ulcer E11.628With other skin complications E11.63With oral complications E11.630With periodontal disease E11.638With other oral complications E11.64With hypoglycemia E11.641With hypoglycemia with coma Ell.649Without hypoglycemia without coma E11.65With hyperglycemia E11.69With other complicationsE11.8XWith other unspecified complicationE11.9XWell controlled without hyperglycemia, hypoglycemia, or complications

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Step 4. Describe Any Identified Complication

This means you will use a primary diabetes code that describes the type of diabetes, then specify whether it is controlled and whether there is a complication, and then add a second code specific to that complication. Sample codes for complications of diabetes are shown in Table 4; codes for common comorbidities are shown in Table 5.

TABLE 4.

Codes for Secondary Diagnosis for Diseases Associated With Diabetes

CodeUsed to report:DermatologyS81.801Open wound, unspecified, right lower legL97.X–L98.XSite of ulcerationL97.411Non-pressure chronic ulcer of right heel and mid-foot limited to breakdown of skinL97.5Non-pressure chronic ulcer of other part of the footL97.533Non-pressure chronic ulcer of other part of left foot with necrosis of muscleNephrologyN18.1Chronic kidney disease (CKD) stage IN18.2CKD stage IIN18.3CKD stage IIIN18.4CKD stage IVN18.5CKD stage VN18.6End-stage renal diseaseR80.9MicroalbuminuriaZ99.2Dependence on renal dialysisE10.42Presence of arteriovenous shunt for dialysisHypoglycemiaE10.649Type 1 diabetes with hypoglycemia without comaE11.649Type 2 diabetes with hypoglycemia without comaE08.64Diabetes due to underlying condition with hypoglycemiaE09.64Drug- or chemical-induced diabetes with hypoglycemiaE16.0Drug-induced hypoglycemia without comaE16.1Other hypoglycemiaE16.2Hypoglycemia, unspecifiedEXX.641Fill in with code for type of diabetes with hypoglycemia and coma

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TABLE 5.

Codes for Common Comorbid Disease Conditions

CodeUsed to report:F17.210Nicotine dependence, cigarettes, uncomplicatedK31.84GastroparesisI10Essential hypertensionHyperlipidemia:E78.0Pure hypercholesterolemiaE78.1Pure hypertriglyceridemiaE78.2Mixed hyperlipidemiaE78.5Hyperlipidemia, unspecifiedHypothyroidism:E06.3Due to Hashimoto’s diseaseE89.0Postoperative or postablativeE03.9AcquiredZ13.29Thyroid disorder screenR94.6Abnormal thyroid blood test or screenE66.0Obesity due to excess caloriesE66.01Morbid severe obesity due to excess caloriesE66.9Obesity, unspecifiedAlso utilize a Z68 code with obesity for BMI:Z68.30BMI 30.0–30.9 kg/m2Z68.31BMI 31.0–31.9 kg/m2Z68.32BMI 32.0–32.9 kg/m2Z68.33BMI 33.0–33.9 kg/m2Z68.34BMI 34.0–34.9 kg/m2Z68.35BMI 35.0–35.9 kg/m2Z68.36BMI 36.0–36.9 kg/m2Z68.37BMI 37.0–37.9 kg/m2Z68.38BMI 38.0–38.9 kg/m2Z68.39BMI 39.0–39.9 kg/m2Z68.41BMI 40.0–44.9 kg/m2Z68.42BMI 45.0–49.9 kg/m2Z68.43BMI 50.0–59.9 kg/m2Z68.44BMI 60.0–69.9 kg/m2Z68.45BMI >70.0 kg/m2G47.33Obstructive sleep apneaE28.2Polycystic ovarian syndrome

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Example 1

A patient has type 2 diabetes with polyneuropathy, hypertension with albuminuria, and dyslipidemia. The coding to document this patient should be E11.65 (type 2 diabetes with hyperglycemia), E11.42 (type 2 diabetes with polyneuropathy), I10 (hypertension), R80.9 (microalbuminuria), and E78.2 (mixed hyperlipidemia).

Example 2

A patient with type 1 diabetes has an active foot ulcer on the bottom of his right foot. The coding to document this patient should be E10.621 (type 1 diabetes with foot ulcer) and L97.411 (non-pressure chronic ulcer of right heel and mid-foot limited to breakdown of skin).

Comorbid conditions affect the complexity of care and the treatments you choose and thus should be coded as diagnoses. One nice feature of the BMI coding shown in Table 5 is that all BMI codes start with Z68, and the digits after the decimal are the actual BMI rounded down to the whole number. In the authors’ experience, coding obesity to the level of the BMI has improved the ability to get coverage for additional medications. This suggests that some insurers may be relying on the coding to make coverage decisions.

Codes to Document Complexity of Care Provided

Finally, there are codes that demonstrate the additional work you do or the additional complexity of the care you are providing. These codes help to justify this higher level of care.

• Did you provide dietary or exercise counseling? These are noted with an additional Z code:

  • ○ Dietary counseling and surveillance: Z71.3

  • ○ Exercise counseling: Z71.89

• Is the patient using insulin? Note that the “long-term use” code Z79.4 can be used once the drug has been initiated for any person who is taking insulin chronically.

• Is the patient on an insulin pump? Codes related to pump use include:

  • ○ Insulin pump: Z96.41

  • ○ Counseling, titration, removal, training, or fitting/adjustment of insulin pump: Z46.81

  • ○ Insulin pump complications: T85.694

• Has the patient underdosed or overdosed insulin? Codes related to these situations include:

  • ○ Underdosing of insulin: T38.3X6

  • ○ Unintentional overdosing of insulin: T38.3X1

  • ○ Suspected self-harm by overdosing insulin: T38.3X2X

After these T codes, there should be a modifier at the end to denote initial encounter (A), subsequent encounter (D), or sequalae (S). For example, an initial encounter for intentional self-harm by overdosing insulin should be “T38.3X2A.”

Codes for Pregnancy in Diabetes

Codes to report pregnancy in women with diabetes include:

• Preexisting type 1 diabetes in pregnancy: O24.01

• Preexisting type 2 diabetes in pregnancy: O24.11

• GDM, diet controlled: O24.410

• GDM, insulin controlled: O24.414

• Obesity complicating pregnancy, unspecified: O99.210

Conclusion

Remember the following steps when coding for patients with diabetes:

1. Document the type of diabetes they have.

2. Document if their diabetes is controlled without any complications.

3. If their diabetes is uncontrolled or they have any complications, document the complications using the codes that fall to the right of the decimal point.

4. Add the secondary diagnosis code to support the diabetes code.

Box 1 offers two case studies to help you apply your knowledge of diabetes coding. Box 2 provides information about additional tools to help providers with ICD-10 coding.

BOX 1. Case Studies for Diabetes Coding

Case 1:
The patient is a 45-year-old man who has had type 1 diabetes for 25 years. At today’s visit, he is diagnosed with gastroparesis. He reports one hypoglycemic episode with a random glucose of 43 mg/dL. His A1C is 7.4%. The patient has a history of nonproliferative retinopathy and CKD stage 1. You provide dietary counseling during the visit. What codes would you use?Answer:

• E10.65: Type 1 diabetes with hyperlgycemia

• E10.43: Type 1 diabetes with gastroparesis (autonomic neuropathy)

• E10.329: Type 1 diabetes with nonproliferative retinopathy

• E10.649: Type 1 diabetes with hypoglycemia

• E10.22: Type 1 diabetes with CKD stage 1

• K31.84: Gastroparesis

• Z71.3: Dietary counseling

• Z79.4: Insulin use

• E11.65: Type 2 diabetes with hyperglycemia

• E11.22: Type 2 diabetes with CKD

• N18.3: CKD stage 3

• E78.2: Mixed hyperlipidemia

• I10: Essential hypertension

• Z79.4: Insulin use

• Z68.37: Obesity

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BOX 2. Tools to Help Providers With ICD-10 Coding

• In many electronic health record systems, providers can type in a description of a condition in words and receive a list of codes from which to choose. Some systems allow providers to type in an outdated ICD-9 code and then provide the corresponding current ICD-10 code.

• There are a number of online tools that can help with coding. Among them are:

  • ○ Centers for Medicare & Medicaid Services websites: https://www.cms.gov/medicare/coding/icd10/2015-icd-10-cm-and-gems.html and https://www.cms.gov/medicare/coding/icd10/providerresources.html

  • ○ The ICD-10 website: https://www.ICD10data.com

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Duality of Interest

J.S. serves as an associate editor for Clinical Diabetes. No other potential conflicts of interest relevant to this article were reported.

References

1. Centers for Disease Control and Prevention National data. Available from http://www.cdc.gov/diabetes/data/national.html. Accessed 7 July 2016

2. Centers for Disease Control and Prevention Annual number and percent distribution of ambulatory care visits by setting type according to diagnosis group. United States, 2009–2010. Available from http://www.cdc.gov/nchs/data/ahcd/combined_tables/AMC_2009-2010_combined_web_table01.pdf. Accessed 7 July 2016

3. American Diabetes Association Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care 2013;36:1033–1046 [PMC free article] [PubMed] [Google Scholar]

4. ICD10data.com. About ICD10data.com. Available from http://www.icd10data.com/About. Accessed 7 July 2016.

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