Keep in mind these coding tips to improve medical record documentation

This article is part of a series of coding tips that’s running through the end of the year.

In the August edition of The Record, we discussed some common documentation and coding challenges for diabetes mellitus. Now, we’ll take a closer look at documentation for renal, ophthalmic, neurological and peripheral circulatory manifestations of this complex condition.

Patients with diabetic manifestations often require more frequent and intensive care by health care providers, and the complexity of these patients’ conditions is often not communicated accurately through documentation or coding. Following are some common errors and tips to keep in mind.

Common documentation and coding challenges for diabetic manifestations

• Documentation doesn’t establish a link between the diabetes to its associated complications and manifestations.
• The note doesn’t indicate how diabetes and its manifestations are managed, evaluated, assessed or treated by the provider. 

Making the connection
A cause-and-effect relationship between diabetes and its manifestations should not be assumed. The relationship should be documented with correct linking words in the progress notes. For example:

• End stage renal disease secondary to diabetes
• Ulceration caused by diabetes
• Polyneuropathy due to diabetes
• Diabetic polyneuropathy

Incorrect linkage
Here’s an example of an assessment with no established link between the diabetes, background retinopathy and Stage IV chronic kidney disease. The assessment doesn’t indicate that retinopathy and CKD are manifestations of diabetes, so all conditions will need to be coded separately:

Assessment: 

• Diabetes type II, controlled                 (250.00)
• Background retinopathy, stable         (362.10)
• CKD stage IV, worsening                    (585.4)

Correct linkage
In contrast, the next documentation example links the manifestations to the diabetes, and the subcategories for ophthalmic and renal manifestations are reported, instead of 250.0X. 

Note: The diabetes code (the cause) is sequenced first. The manifestation code (the effect) is sequenced second. Both codes are required to accurately report the condition.

Assessment:

• Background retinopathy due to Type II diabetes, controlled   (250.50, 362.01)
• Stage IV CKD caused by Type II diabetes         (250.40, 585.4)

Use of ‘with’ as a linking word
Many of the ICD-9-CM subcategory titles for diabetes use the word ‘with’ to express linkage between diabetes and the related manifestation, such as diabetes with renal manifestations. According to ICD-9-CM guidelines, the word ‘with’ should be interpreted to mean ‘associated with’ or ‘due to’ when it appears in the code title, the Alphabetic Index or an instructional note in the Tabular List of the ICD-9-CM. 

Although the word ‘with; is considered acceptable linkage within the context of the ICD-9-CM, BCBSM does not consider the word ‘with’ to be an acceptable linking word in provider documentation. The words ‘secondary to,’ ‘caused by,’ ‘due to’ or ’diabetic’ show a stronger causality in documentation. 

When a code is selected for an assessment, many electronic medical record systems automatically generate the ICD-9 subcategory description within the patient note. Use of only an ICD-9-CM subcategory title won’t substantiate linkage for diabetes manifestations. Please use the appropriate linking words.

Manage, evaluate, assess or treat, also referred to as MEAT
Providers must clearly identify a patient’s diagnosis in a progress note for an ICD-9-CM code to be valid. For example, "diabetes type II, uncontrolled" cannot be coded if the only documentation is "A1c of 9.9 and abnormal blood sugar of 284." Additionally, the assessment and plan for each diagnosis should indicate how each condition was managed, evaluated, assessed or treated, and this information should be clearly connected to each individual diagnosis.   

Here’s an example of how to properly code using the MEAT components:

Assessment and plan

1. Peripheral neuropathy caused by diabetes type II, uncontrolled (250.62, 357.2)
   Reviewed A1c, levels elevated at 11 percent
   Begin NPH insulin, 15 units SQ, per day
   Insulin education performed
   Refilled Topamax, 200 mg twice a day orally as needed for peripheral neuropathy

2. Benign hypertension, stable (401.1)
   Continue Diovan, 80 mg per day orally

It’s important that each diagnosis is supported with clear linkage to the components of MEAT.

Mastering how to accurately document diabetes and its manifestations is the first step in coding for this complex condition.

Next month’s article in this series will focus on code selection tips for diabetic manifestations.