ICD-10 Changes for Diabetes Just the Beginning for Endocrinologists

As with many specialties, endocrinology will see several diagnosis code expansions and changes in ICD-10. 
Although EHRs will certainly help guide physicians, it’s important for physicians to understand the logic behind the changes and how they may eventually improve clinical care protocols. Betty Hovey, CPC, COC, CPB, CPMA, CPC-I, CPCD, director of ICD-10 development and training at the AAPC provides an overview of some of ICD-10 changes for several conditions relevant in this specialty.

1. Diabetes. ICD-10 now includes a whole host of combination codes that denote the specific type of diabetes as well as any complications or manifestations. The biggest change for physicians is the elimination of designations such as “controlled” and “uncontrolled.” Instead, the ICD-10 index directs coders/physicians to record diabetes by type. Consider these tips for compliant documentation:

• Document the cause of type of diabetes (i.e., secondary due to underlying condition, drug- or chemical-induced, type 1, type 2, or other).
• Document the presence of any organ system affected (e.g., kidney, neurological, or circulatory).
• Document any specific complications (e.g., polyneuropathy, hyperglycemia with coma, or cataract).
• Identify whether the patient is insulin-dependent (for patients with non-type 1 diabetes).

Consider these tips when selecting a code in the EHR or circling a code on an encounter form:

• Note that gestational diabetes is in a separate code category: O24.-.
• Although diabetes is a combination code in ICD-10, there may be instances in which coders/physicians need to assign an additional code. Assign an additional code for the following, when applicable:
• Underlying conditions (e.g., congenital rubella, Cushing’s syndrome, cystic fibrosis, malignant neoplasms, malnutrition, or pancreatitis)
• Insulin use (for patients with non-type 1 diabetes)
• Specific stage of chronic kidney disease
• Specific site of the diabetic ulcer, including specific anatomical location, laterality, and severity
• Poisoning due to drug or toxin
• Specific drug or toxin that causes the adverse effect
• Note that coders/physicians may need to report multiple diabetes codes if patients have more than one complication or manifestation. For example, a patient presents with type 2 diabetes with diabetic neuropathic arthropathy as well as diabetic dermatitis. Report E11.610 as well as E11.620.

Endocrinology practices may want to consider creating a separate cheat sheet specifically for diabetes that includes codes for diabetic pressure ulcers. Non-pressure ulcer codes are incredibly detailed in ICD-10, requiring physicians to capture severity as follows:

• Limited to breakdown of skin
• With fat layer exposed
• With necrosis of muscle
• With necrosis of bone

2. Menopause. ICD-10 separates premature menopause into asymptomatic vs. symptomatic. Be sure to document any symptoms such as flushing, sleeplessness, headache, or lack of concentration associated with the premature menopause.

3. Goiter. ICD-10 includes codes for iodine-deficiency related goiter. Be sure to document whether this type of goiter is diffuse (endemic) or multinodular (endemic).

4. Cushing’s syndrome. ICD-10 codes for Cushing’s syndrome now denote the following types/causes, each of which must be reflected in physician documentation:

• Pituitary-dependent
• Nelson’s syndrome
• Drug-induced
• Ectopic ACTH syndrome
• Alcohol-induced pseudo

5. Gout. As with many diagnosis codes in ICD-10, gout now includes specific anatomic location and laterality. Be sure to document the following elements:

• Cause (i.e., idiopathic, drug-induced, secondary to renal impairment, or other causes)
• Episode (i.e., chronic, acute, flare, attack, or podagra)
• Location (e.g., right foot, left hand, right elbow)
• With or without tophi (for chronic gout)

6. Endocrine and metabolic disorders. In general, endocrinologists should specify the disorder, disease, defect, deficiency or syndrome as well as any underlying conditions and the significance of any abnormal lab findings. For vitamin/mineral/other nutritional deficiencies, specify the specific vitamin and/or mineral. For metabolic disorders, specify the amino acid, carbohydrate, or lipid enzyme deficiency responsible for the metabolic disorder.

General ICD-10 tips

The sheer number of codes has increased significantly in ICD-10. Many of the diagnoses that endocrinologists report frequently are among these expansions. It’s important to understand coding and documentation changes to ensure accurate revenue and data integrity. Consider these tips:

• Work with your EMR vendor to ensure that all ICD-10 diagnoses are captured correctly and with as much detail as possible.
• Don’t select the first diagnosis code that appears in the EMR. Dig deeper to ensure that the code you select is an accurate depiction of the patient’s presentation.
• If the practice uses a superbill or encounter form, ensure that this document has been updated for ICD-10. Double check all codes for accuracy. Also consider deleting diagnoses that the practice doesn’t report frequently to make space for diagnoses that have been expanded in ICD-10.
• Avoid unspecified codes, when possible. For example, documentation such as “diabetic ulcer” maps to type 2 diabetes with an additional code for an unspecified ulcer with unspecified location and severity. Payers and auditors will likely penalize practices for these types of codes.

For more ICD-10 tools and resources, visit the ICD-10 Resource Center.