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Resolved HCC Query Diabetes and Its Complication

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Please let me know can we code a combination code for diabetes and its complications if linkage is not mentioned in the medical report.

For example, if the patient has diabetes and specific type of glaucoma and we get MEAT for both of them, can we code E11.39 (Type 2 diabetes mellitus with other diabetic ophthalmic complication) and code for glaucoma with diabetes complication dx.

Also, can we assume causal relationship between diabetes and its complication even if the linkage (with or due to) is not mentioned in the medical report by the physician and code a combination dx if we get MEAT for both the diagnoses code?

Thank you in advance.
 
Please let me know can we code a combination code for diabetes and its complications if linkage is not mentioned in the medical report.

For example, if the patient has diabetes and specific type of glaucoma and we get MEAT for both of them, can we code E11.39 (Type 2 diabetes mellitus with other diabetic ophthalmic complication) and code for glaucoma with diabetes complication dx.

Also, can we assume causal relationship between diabetes and its complication even if the linkage (with or due to) is not mentioned in the medical report by the physician and code a combination dx if we get MEAT for both the diagnoses code?

Thank you in advance.

Hello!

Per the ICD-10-CM Coding Guidelines “The word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index (either under a main term or subterm), or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for “acute organ dysfunction that is not clearly associated with the sepsis”).”

According to the “with” guideline above, we can link certain conditions for DM with complications; however, per Coding Clinic (2018, Issue 2), the “With” Guideline does not apply to “not elsewhere classified (NEC)” index entries that cover broad categories of conditions. Specific conditions must be linked by the terms “with,” “due to” or “associated with.” So, your question regarding diabetes and a specific type of glaucoma being linked without the provider linking the glaucoma to the diabetes, we would not be able to link glaucoma to diabetes since code E11.39 (ophthalmic complication NEC) is a NCE code. However, if the patient were to have cataracts and diabetes and the provider did not link the two conditions and the cataracts was not documented as being due to another condition, then you would be able to link the cataracts to the diabetes since code E11.36 (Type 2 diabetes mellitus with diabetic cataract) is not a NCE code.

Here is a little tip I did when I first started out in HCC coding, which helped me. In my ICD-10-CM book, for example, in the Alphabetical Index under Diabetes/ with, I highlighted all the codes under the subterm “with” that were NCE codes which let me know those codes required the provider to link the condition to the diabetes. So, for example, arthropathy NEC E11.618, circulatory complication NEC E11.59, E11.39 ophthalmic complication NEC, etc., I highlighted.
 
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Hello! I'm so glad you asked this question. Does this also apply to Senile Nuclear Sclerosis (Cataract>senile>nuclear)? Since H25.1 is not an HCC code, but the patient has Diabetes, could it fall under E11.36?
 
Thank you so much Tiffancy for answering my query. I don't have ICD-10-CM book, so can you please give us the list of combination codes where we can assume linkage with diabetes, that would be very helpful as I am new to HCC coding.

Thanks again.
 
Hello! I'm so glad you asked this question. Does this also apply to Senile Nuclear Sclerosis (Cataract>senile>nuclear)? Since H25.1 is not an HCC code, but the patient has Diabetes, could it fall under E11.36?
Hello!

Yes, even though H25.1- does not carry an HCC, E11.36 would still be reported as it carries an HCC. However, keep in mind depending on the type of project you are working on or your client specific guidelines, code H25.1- may also be reported. For example, if you were working on a complete code capture project for risk adjustment, both codes would then be reported.
 
sThank you so much Tiffancy for answering my query. I don't have ICD-10-CM book, so can you please give us the list of combination codes where we can assume linkage with diabetes, that would be very helpful as I am new to HCC coding.

Thanks again.


Here is more info on causal relationships:

Diabetes mellitus with complication The combination code for diabetes includes the type of diabetes, the body system that is affected and the specific complication affecting that body system. There is an assumed cause-and-effect relationship between diabetes and certain conditions (such as but not limited to: cataract, dermatitis, gastroparesis, chronic kidney disease, osteomyelitis, retinopathy and [poly]neuropathy) as these specific conditions are listed under the term “with” in the Alphabetic Index.2 For example, the documentation does not need to contain a link between the diagnosis of diabetes and neuropathy in order to assign code E11.40 — type 2 diabetes mellitus with diabetic neuropathy. However, if diabetes is not the underlying cause of neuropathy, it should be documented as such and, therefore, not coded as a diabetic complication.

You can access an online ICD-10-CM here but you really should have an ICD-10 manual to take the ICD-10 Blitz with CCO which you are enrolled in.


These codes need to be specific for your documentation regarding Type 1 or 2 etc. so we can not provide a more specific list with codes.

Here’s a list of the associated diabetic conditions where the link is assumed in ICD-10-CM:​

  • amyotrophy
  • arthropathy NEC
  • autonomic (poly) neuropathy
  • cataract
  • Charcot’s joints
  • chronic kidney disease
  • circulatory complication NEC
  • complication
  • specified NEC
  • dermatitis
  • foot ulcer
  • gangrene
  • gastroparalysis
  • gastroparesis
  • glomerulonephrosis, intracapillary
  • glomerulosclerosis, intercapillary
  • hyperglycemia
  • hyperosmolarity
  • with coma
  • hypoglycemia
  • with coma
  • ketoacidosis
  • with coma
  • kidney complications NEC
  • Kimmelsteil-Wilson disease
  • loss of protective sensation(LOPS) – see Diabetes, by type, with neuropathy
  • mononeuropathy
  • myasthenia
  • necrobiosis lipoidica
  • nephropathy
  • neuralgia
  • neurologic complication NEC
  • neuropathic arthropathy
  • neuropathy
  • ophthalmic complication NEC
  • oral complication NEC
  • osteomyelitis
  • periodontal disease
  • peripheral angiopathy
  • with gangrene
  • polyneuropathy
  • renal complication NEC
  • renal tubular degeneration
  • retinopathy
  • skin complication NEC
  • skin ulcer NEC
This post has more info:

When “With” Assumes a Causal Relationship​

 
Hello!

Yes, even though H25.1- does not carry an HCC, E11.36 would still be reported as it carries an HCC. However, keep in mind depending on the type of project you are working on or your client specific guidelines, code H25.1- may also be reported. For example, if you were working on a complete code capture project for risk adjustment, both codes would then be reported.
Thank you so much Tiffany! I am going to save this list for future reference.
 
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