Diabetes Mellitus

High quality documentation and complete, accurate coding can help capture our members' health status and promote continuity of care. Below are tips for documenting and coding diabetes mellitus (DM). This guidance is from the ICD-10-CM Official Guidelines for Coding and Reporting  and industry-approved sources.

Codes for DM Types

DM types are divided into five categories:

• E08 DM due to underlying condition
• E09 Drug or chemical induced DM
• E10 Type 1 DM
• E11 Type 2 DM
• E13 Other specified DM

ICD-10-CM requires documentation to specify DM with hyper- or hypoglycemia, instead of controlled or uncontrolled. Without this documentation, DM unspecified will be coded.

Specificity Matters
These categories are further divided into subcategories of four, five or six characters. They include the DM type, the body system affected and the complications affecting that body system.

A relationship is assumed for conditions listed under "with" in the ICD-10 Alphabetic Index. The DM combination code will be appended unless documentation specifically states a relationship doesn’t exist. For example, the combination code E11.65 is appropriate for Type 2 DM with hyperglycemia, rather than two separate codes for these conditions.

Best Practices

• Include patient demographics, such as name and date of birth, and date of service in all progress notes.
• Document legibly, clearly and concisely.
• Ensure documents are signed and dated by a credentialed provider.
• Document each diagnosis as having been monitored, evaluated, assessed and/or treated on the date of service.
• Note complications with an appropriate treatment plan.
• Assign as many codes as needed to describe all disease complications. This includes combination codes (such as E11.621 Type 2 DM with foot ulcer) and additional codes (such as CKD stage and ulcer site).
• For patients who routinely use insulin, assign code Z79.4, Long term (current) use of insulin. Note: Z79.4 shouldn’t be assigned if insulin is given to bring a patient’s blood sugar temporarily under control during an encounter.
• Take advantage of the Annual Health Assessment (AHA) or other yearly preventative exam to capture all conditions impacting member care.

Coding Example

Progress Note: A/P Mrs. Garcia presents today with multiple issues. Her Type 2 diabetes is controlled with current Metformin regimen; continue dose. No changes to CKD III. Lab work performed to confirm. Back pain has not improved since last visit. Suggested chiropractor as next step since over-the-counter medications and yoga have not provided adequate relief. Renewed bouts of depressed mood due to inability to find relief from back pain. Mrs. Garcia has a long-standing relationship with a mental health provider for her recurrent depression (see BH consult note 6/2020). Will initiate contact with BH provider for a follow-up visit.

DM codes: E11.22, N18.30

For more details, see:

• 2020 ICD-10-CM Official Guidelines for Coding and Reporting , Chapter 4: Endocrine, Nutritional and Metabolic Diseases (E08–E13)
• Centers for Medicare & Medicaid Services Risk Adjustment Data Validation (RADV) Medical Record Checklist and Guidance 
• BCBSNM Medicare Advantage Annual Wellness Visit Guide

Questions? Contact your BCBSNM Network Representative.

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_{The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.}