Coding corner: Best practices for documenting diabetes

With the implementation of ICD-10-CM and coding classification changes, documenting the nuances of diabetes is more important than ever.

Providers either report Type 1 diabetes for patients who don’t produce insulin or Type 2 diabetes for patients who produce insulin but their bodies don’t use it correctly.

To improve documentation and coding practices, it’s essential that medical records provide details on all diabetes-related conditions to the highest level of specificity known.

When documenting diabetes, consider the following:

• Specify whether it’s Type 1 or Type 2 diabetes.
• Is the diabetes due to a condition or a drug? If it’s due to a drug, indicate which one.
• Is this a secondary type of diabetes? If so, what’s the cause?
• Specify when diabetes is gestational.
• Was there an incidence of underdosing or overdosing (poisoning)? For example: Did the patient receive too much or not enough insulin?

How to improve progress notes
Only providers can diagnose a patient’s medical condition, making documentation even more important. Even if a medical coder can recognize the inference of a condition, only what is documented can be coded.

For instance, if a patient has two medical conditions that are linked, then his or her provider needs to document that the conditions are related. This allows coders to use a combination code, which is a single code used to describe two diagnoses (a diagnosis with either an associated manifestation or complication).

Example: Type 1 diabetic mellitus with severe nonproliferative diabetic retinopathy with macula edema

Here are three examples of when a report lacks documentation or doesn’t properly link two conditions:

1. A patient visits his podiatrist for an annual diabetic exam. The podiatrist documents a prescription for new shoes. The assessment shows the patient is instructed to return in one year.

What’s wrong with this documentation?

• The medical coder can’t code the patient’s medical condition as diabetes because the provider didn’t document the patient as being diabetic.

• The annual diabetic exam may have only been for monitoring purposes; it doesn’t prove the patient has the condition.

2. A patient visits his podiatrist for an annual diabetes exam. The podiatrist documents a prescription for new shoes. The assessment shows the patient understands the importance of checking his feet, because his diabetic condition makes his feet prone to other health issues.

What’s wrong with this documentation?

• The provider’s note only states the patient is diabetic.

• The documentation needs to state any linked or additional diagnoses. Peripheral neuropathy maybe suspected based on the prescription for diabetic shoes, but the provider didn’t document that condition.

3. A patient visits his podiatrist for an annual diabetes exam. The podiatrist documents a prescription for new shoes. The assessment shows peripheral neuropathy and that the patient understands the importance of checking his feet, because his diabetic condition makes his feet prone to other health issues.

What’s wrong with this documentation?

• The documentation supports two separate diagnoses; therefore a combination code can’t be used.

• To link two medical conditions together, there needs to be verbiage in the record such as “with,” “due to” or “associated with.”

It’s equally important for everyone involved in the patient’s care to understand the relationship of the conditions found in the progress notes. Documenting the cause and effect of a condition in the medical record provides a complete picture of the patient’s office visit.

The ICD-10 code assignment is crucial in determining the correct reimbursement for these face-to-face encounters and for tracking health care services provided for a diabetic condition.

Requirements for reporting diabetes mellitus and its associated illnesses are located in the ICD-10-CM coding book, “Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00 — E89).”

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.