The International Classification of Diseases, Tenth Revision (ICD-10) provides specific guidelines for coding diabetes and its related complications. The guidelines include the following:
- Diabetes Mellitus (E08-E13):
- Assign codes E08-E13 to identify the type of diabetes mellitus (Type 1, Type 2, other specified types or unspecified type) as documented in the medical record.
- If the patient has both Type 1 and Type 2 diabetes, assign codes for both.
- When both diabetes and its complications are present, the complications should be coded as well.
- Complications of Diabetes Mellitus (E08-E13 with a 4th or 5th digit):
- Assign codes to identify all complications of diabetes mellitus, including those associated with the circulatory, nervous, renal, and ocular systems.
- When the documentation doesn’t specify the type of diabetes, assume it to be Type 2 diabetes.
- When a patient has both diabetes and its complications, code both.
- Hypertensive Diabetic Chronic Kidney Disease (N18.1):
- Assign code N18.1 to identify hypertensive chronic kidney disease (CKD) in patients with diabetes mellitus.
- When a patient has hypertensive CKD and diabetes, assign both codes.
- Diabetic Retinopathy (E08-E13 with a 7th digit of 0, 1, 2, 3 or 4):
- Assign codes E08-E13 with a 7th digit to identify the stage of diabetic retinopathy (0, no retinopathy; 1, mild nonproliferative diabetic retinopathy; 2, moderate nonproliferative diabetic retinopathy; 3, severe nonproliferative diabetic retinopathy; or 4, proliferative diabetic retinopathy).
- Peripheral Vascular Disease (I73.9):
- Assign code I73.9 to identify peripheral vascular disease in patients with diabetes mellitus.
It is important to accurately code diabetes and its related complications to ensure proper reimbursement and to provide accurate epidemiological data. It is also important to follow the official ICD-10-CM coding guidelines when assigning codes.