Today we are going to talk about
Chapter 4 guidelines in the ICD-10-CM code book.
Specifically, diabetes is covered,
very much so, in these guidelines. Some
things you need to remember about coding
diabetes. You can code as many codes as
you need to code to fully describe an
encounter. Often a person with diabetes
will have many complications or
manifestations of the disease that need
to be included and then you have
combination codes so the code
would represent diabetes with whatever
the situation is. It's okay to use as
many of those as you need to code. Their
sequence, or which one goes first, will be
based on the reason for the encounter,
whether it's the admission to the
hospital or why they're in the doctor's
office. As I said earlier, you can
assign as many categories, as many
codes as you need to from those
categories to identify all the
associated conditions. The first
guideline has to do with the default.
That means if the documentation does not
tell the coder what type of diabetes a
patient has, the guideline instructs
us to code to the default which is
E11.- which is Type 2.
Remember that dash tells you
additional characters are needed so if
there's no other complications with this
person with diabetes, it's
going to be an
E11.9 indicating he does have diabetes, no
complications or other specified
problems and the hypertension is I10.
The next guideline has to do with the
use of insulin and oral hypoglycemics.
The 2017 guidelines added a code for the use
of oral hypoglycemics. The use of
insulin was already in the codebook and in
the guidelines but in this scenario the
doctor documents the patient's new to
our practice with the diagnosis of
diabetes and uses insulin to control
her blood sugar. The Guideline tells us if
the documentation does not indicate the
type of diabetes but does indicate the
patient uses insulin, you're going to
code Type 2, E11, meaning you're going to go
into that category and choose the code
to have the correct characters. No
complications are mentioned so E11.9
would be the correct code for the
diabetes and then the use of insulin
to control the blood sugar would be Z79.4
and you see in the index, that comes
under "long-term drug therapy." Then I
have a note at the bottom of the slide
that if a patient is in the ER, for
example, and insulin is given to bring
down their blood sugar temporarily but not
long term and then you would not code
that Z79.4. That is only for the
use of insulin long term. This is the
same scenario, only this time the doctor
has documented the patient is using oral
hypoglycemic medication which is a
different code Z79.84. It also comes under
long-term drug therapy. The next
guideline has to do with diabetes in
pregnancy and diabetes that is
gestational, both of those conditions
refer the coder to Chapter 15 which is
the OB chapter in the code book. We won't
spend too much time on this but I wanted
to at least introduce it and then know
that you will often see codes for
pregnancy complicated by whatever the
situation is and when you look at
diabetes, there is an entry, a sub-term
for pre-existing type 1. I also have here
on the left a note to you that the coder
must be alert to the difference between
the letter "O" and the number "0". They don't
look the same so you have to be sure if
you are handwriting, for example, I would
put a mark through the zero to indicate it is a zero
but if you're typing you simply have to
really read carefully.
In ICD-10-CM, the first character in a
code is not a number so it has to be the
letter "O" if it's part of a code. 024.0.12 is the code for pregnancy complicated
by diabetes, pre-existing type 1. You
notice that in the index there is 024.01-.
The dash is the last character,
the sixth character, which is the
trimester. I have a note on the left
that 16 weeks is the second trimester so
"2" would be your 6th character in that
code. Type 1 diabetes codes to E10.9
and then whenever we are coding
pregnancy, we are going to be coding weeks of
gestation and that's the Z3A.16.
Then I have the guideline from Chapter 15 telling us
we have to use the category 024 for
the diabetes followed by the appropriate
diabetes code. This is not the same as
gestational diabetes. That's a separate
diagnosis and a separate guideline and a
different code. (For) Pre-existing, obviously
the patient had the diabetes before the
pregnancy. For gestational, that is when the
patient has developed diabetes as a
result of the pregnancy. The next guideline
has to do with the underdose of insulin
due to insulin pump failure.
When pumps fail, they're either going to
deliver too much insulin or too little.
Underdosing, if you remember from the
Table of Drugs and Chemicals, underdosing
has a unique column specific to that type
of problem. T38.3x6 and then we would add a
seventh character for the initial
encounter, however, the first code the T85,
the complication of the pump due to a
mechanical breakdown, is your principal
diagnosis and if you read there in your
guidelines, under the rationale, it tells
you to assign a code T85.6 that
specifies the type of pump malfunction
as the principal (diagnosis)and that's followed by
code T38.3x6-
underdosing of insulin and oral
hypoglycemic and then additional codes
for the type of diabetes and any
associated complication due to the
insulin underdosing. The next
slide has to do with the overdose of
insulin due to insulin pump failure and
in this case, an overdose falls in the
"poisoning" column in the Table of Drugs and
Chemicals. Again T85 would be the
category that would be our principal
diagnosis followed by the code for the
poisoning or the overdose of the insulin,
then the type of diabetes with any
resulting problems because of this. In
this case, the patient's being treated for
hypoglycemia with her
diabetes. Let's talk for a bit about
secondary diabetes. Secondary diabetes
is always caused by another condition
or an event. Examples are cystic fibrosis,
cancer of the pancreas, a pancreatectomy or
in other words, the removal of the
pancreas or an adverse effect of a drug
or poisoning. As a reminder, adverse
effect means the patient has taken the
medication in the prescribed dose in the
prescribed manner and still had an
adverse effect. A poisoning is if the
patient has taken too much of the
medication or more than was prescribed
by the physician. Codes under categories
E08, which is due to underlying
condition, E09 which is drug or
chemical induced and E13 which are
other types of specified diabetes. You're
going to identify any complications that
are associated with that secondary
diabetes mellitus and the sequencing of
the secondary codes is going to be given in
the instructional notes that follow the
codes in those categories. Always look to
your instructional notes in the Tabular
to help you know how to sequence these
codes. This slide has to do with secondary
diabetes due to a pancreatectomy or the
removal of the pancreas.
The diagnostic statement tells us
the patient has no complications related
to diabetes and uses insulin to control
diabetes. If you read the guideline, it
tells you the codes that you're going to
be needing, at a minimum, and then when
you look up your codes, it also tells you
in instructional notes the code you're
going to be needing. So it's not a lot of
guesswork here. The guidelines actually tell
you exactly how to sequence these codes.
E89.1 is your postprocedural
hypoinsulinemia and you see also when
you look it up in the index, you can
show you a post-pancreatectomy
hyperglycemia. Those two things, one says hypo-, one says
hyper-, the fact that you have
not enough insulin, a a hypoinsulinemia
leads to the patient developing hyper-
(too much sugar) hyperglycemia so they are
connected but they are correct as
written. You're going to assign a code
from category E13 which is your diabetes
specified type according to your
guidelines. It tells you exactly what to
code and then code Z90.41- to
show the acquired absence of the
pancreas because it's been removed and
then the statement tells us insulin is being used
so you going to add the Z79.4 so at a
minimum, you would have four codes for
secondary diabetes due to pancreatectomy.
You can also develop secondary diabetes
due to drugs and the example I have given
you here is taken from one of your homework
exercises where the patient has
developed diabetes with diabetic
nephropathy following the use of this
drug physostigmine which is an
anti-cholinesterase agent. Nephropathy, if
you remember from your medical
terminology, "nephro" means
kidney, so the patient has developed
kidney problems following the use of this
drug. It tells us that the patient did
not take any more of the drug than was
prescribed. It also tells us why the
patient was receiving this drug, to
augment muscular contractions in the
treatment of myasthenia gravis without
exacerbation. The patient has used insulin to
to manage diabetes since this
developed and this is a subsequent
encounter. Remember, subsequent is the
letter "D" as your 7th character. There
are guidelines in Chapters 19 and 20
which are where it says here in the
rationale, "See Section I.C.19 e and I.C.20"
to tell you how to sequence those. I didn't
reproduce those for the sake of saving
space but you can see how E09.21 code
first, then the T49 is the adverse effect
of the drug and I said adverse effect
because of the statement tells
us the patient did not take any more of the drug than
was prescribed. Long term therapy of
insulin Z79.4 and the
myasthenia gravis, we want to also code.
That's all the guidelines I am going to go
over for Chapter four. If you have any
questions relating to these guidelines,
please post them in the discussion board.
If you have a specific code that you're
looking for, please post the pathway you
used to look for your answer and
I will answer your question there. Thank
you so much and have a good day.