DIABETES MELLITUS (DM) - Cigna
DIABETES MELLITUS (DM)
Provider's guide to diagnose and code Diabetes Mellitus
Background
According to a (2014) report by the Centers for Disease Control (CDC):
> Approximately 29 million Americans
have type II diabetes
? Over 11 million people aged 65 and older have the diagnosis1
> Approximately 200,000 people have type I diabetes
> Nearly 14% of American health care dollars
are spent on DM related care
ICD-10 code documentation:
> "Controlled/Uncontrolled" classification has been
eliminated for ICD-10, therefore inadequately,
out of control, or poorly controlled are
coded by DM type with hyperglycemia
> Uses 5 categories to identify the clinical manifestation
? E08: DM
? E09: Drug or chemical induced DM
? E10: Type 1 DM
? E11: Type 2 DM
? E13: Other specified DM
> Uses a 3rd character to denote the type of DM
> Uses a 4th character to denote the
type of DM complication
> Uses a 5th and 6th character to denote the sub
classification of the body system complication
> Uses a single code to identify type
of DM and the complication
> In most cases a single code reports both
the DM and the complication
> Additional codes required for CKD stage,
glaucoma, and ulcer site complication
> Uses a (-) dash instead of (x), this indicates the code
requires further characters to account for specificity
> Rejects non-specific codes > Requires that insulin be coded as Z79.4 > Documents DM complications > Illustrates the cause and effect relationship
with conclusive linking words
? Example: Renal failure secondary to diabetes
Use conclusive linking words
Due to Caused by Secondary to
Avoid inconclusive linking words
Probably Suspected Likely
Diagnosing
ADM as controlled or uncontrolled is based on:
> Symptoms > Related diseases > Glycated hemoglobin (HgA1c) > Provider's clinical judgment
Though there are varying definitions of "controlled," The American Diabetes Association (2014) recommends that the HgA1c target should be:
> 7% percent in most cases
> 8% in certain cases when there is:
? A history of severe hypoglycemia ? Limited life expectancy ? An elderly patient2 Uncontrolled DM is diagnosed when the current treatment regimen does not keep the blood sugar level within acceptable levels.
Note: If unsure of the diagnosis, then the condition should be coded to the highest degree of certainty
Important tips
1. Be legible, clear and concise 2. Avoid acronyms 3. Ensure document is signed and dated
by a credentialed provider 4. Each diagnosis must have an assessment
and a treatment plan and follow-up 5. Verify patient demographics, such
as name and date of birth 6. Make sure there is a date of service
with the clinical encounter 7. Complications need to be documented with an appropriate
treatment plan. See the Tips & Linking table for assistance.
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Corporation. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
? 2015 Cigna
INT_15_31322 06292015
2015 ICD-10-CM
ICD-10 Description CM Code
Definition / Tips
E10.9 E11.9 E10.2 E11.2 E10.3 E11.3
E10.4 E11.4
Type 1 DM w/o complications Type 2 DM w/o complications Type 1 DM w/kidney complication
Type 2 DM w/kidney complication Use additional code to identify insulin use (Z79.4) Type 1 DM w/ophthalmic complication Type 2 DM w/ophthalmic complication Use additional code to identify insulin use (Z79.4)
Type 1 DM w/neurological complication Type 2 DM w/neurological complication Use additional code to identify insulin use (Z79.4)
(-) Add 5th character: 1 ? diabetic nephropathy 2 ? diabetic CKD
*Use additional code to identify stage of CKD (N18.1-N18.6)
9 ? other diabetic kidney complication
(-) Add 5th and 6th characters: 11 ? unspecified diabetic retinopathy w/macular edema 19 ? unspecified diabetic retinopathy w/o macular edema 21 ? mild non-proliferative diabetic retinopathy w/macular edema 29 ? mild non-proliferative diabetic retinopathy w/o macular edema 31 ? moderate non-proliferative diabetic retinopathy w/macular edema 39 ? moderate non-proliferative diabetic retinopathy w/o macular edema 41 ? severe non-proliferative diabetic retinopathy w/macular edema 49 ? severe non-proliferative diabetic retinopathy w/o macular edema 51 ? proliferative diabetic retinopathy w/macular edema 59 ? proliferative diabetic retinopathy w/o macular edema 6 ? w/diabetic cataract 9 ? w/other diabetic ophthalmic complications Use additional code to identify glaucoma (H40-H42)
(-) Add 5th character: 0 ? diabetic neuropathy, unspecified 1 ? diabetic mononeuropathy 2 ? diabetic polyneuropathy 3 ? diabetic autonomic (poly)neuropathy
(gastroparesis) 4 ? diabetic amyotrophy 9 ? other diabetic neurological complication
2015 ICD-10-CM
ICD-10 Description CM Code
Definition / Tips
E10.5 E11.5 E10.6 E11.6
E10.8
Type 1 DM
w/circulatory complication
Type 2 DM
w/circulatory complication
Use additional code to identify insulin use (Z79.4)
(-) Add 5th character: 1 ? diabetic peripheral angiopathy w/o gangrene 2 ? diabetic peripheral angiopathy w/gangrene 9 ? w/other circulatory complications
(-)Add 5th and 6th characters: 10 ? diabetic neuropathic arthropathy 18 ? other diabetic arthropathy 20 ? diabetic dermatitis 21 ? w/foot ulcer
Use additional code for ulcer site (L97.4, L97.5) 22 ? w/other skin ulcers
Use additional code for ulcer site (L97.-, L98.-) 28 ? w/other skin complications 30 ? w/periodontal disease 38 ? w/other oral complications 41 ? w/hypoglycemia w/coma 49 ? w/hypoglycemia w/o coma 5 ? w/hyperglycemia 9 ? w/other specified complication
Use additional code to identify complication
Type 1 DM w/unspecified complication
E11.8
Type 2 DM w/unspecified complication
Use additional code to identify insulin use (Z79.4
References: 1. Centers for Disease Control. (2014). National Diabetes Statistic Report. DOI:
pubs/statsreport14/national-diabetes-report-web.pdf
2. American Diabetes Association. Standards of medical care in diabetes--2014. Diabetes Care, 37, Suppl 1:S14.
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