ICD 10 Coding Guidelines for Diabetes and its Complications

Diabetes has a lot of associated conditions. The combine ICD 10 codes of diabetes and associated condition has been a big confusion for medical coders. If you are a medical coder, then you would have understood what I mean to say.

Several questions were raised by coders for clarification in coding these combined codes of diabetes with associated condition.  The main question was that whether the coder should assume a causal relationship between diabetes and it associated condition, when both are documented by physician in the report.

Finally, the updated coding guidelines has clearly mention that the word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, 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. 

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Below is an example for diabetes with associated condition.

Diabetes, diabetic (mellitus) (sugar) E11.9 

  with 

amyotrophy E11.44 

arthropathy NEC E11.618 

autonomic (poly) neuropathy E11.43 

cataract E11.36 

Charcot’s joints E11.610 

chronic kidney disease E11.22 ;

The subterm “with” in the index should be interpreted as a link between diabetes and any of those condition indented under the word “with”. So, the physician documentation is not needed to confirm a link between the diabetes and its associated condition.

So, next time if you come across diabetes and chronic kidney disease in the report, just assume a relationship between them and code E11.22. Same guidelines should be followed with the other conditions under subterm “with”. These condition can be coded as related even in the absence of provider documentation.

Only when the provider clearly states that these two conditions (diabetes and associated condition) are unrelated to each other, then only these two conditions can be coded separately.

Note: The ICD-10-CM classification presumes a causal relationship between diabetes and several acute and chronic conditions. The term “with” means “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. For example, under the Alphabetic Index main term Diabetes, the subterm “with” indicates a range of conditions in which the classification assumes a linkage between the condition—such as dermatitis, foot ulcer, or gangrene—and the diabetes. However, if the physician documentation specifies that diabetes mellitus is not the underlying cause of the other condition, the condition should not be coded as a diabetic complication.

The “with” guideline does not apply to “not elsewhere classified” (NEC) Index entries that cover broad categories of conditions. Coding professionals should not assume a causal relationship when the diabetic complication is classified as “NEC.” Specific conditions must be linked in the patient’s medical documentation by the terms “with,” “due to,” or “associated with.” An example is the Index main term Diabetes, subterm “with,” sub-subterm “skin complication NEC.” To link diabetes and a specific skin complication NEC, such as cellulitis or acne vulgaris, the provider would need to document the condition as a diabetic skin complication.

When the coding professional is unable to determine whether a condition is related to diabetes mellitus, or the ICD-10-CM classification does not provide coding instruction, it is appropriate to query the physician for clarification so that the appropriate codes may be reported.

If the provider has confirmed a diagnosis of diabetes mellitus, the appropriate code from categories E08–E13, Diabetes mellitus, should be assigned. Otherwise, a diagnosis of “borderline diabetes,” “prediabetes,” or “latent diabetes” should be assigned to code R73.03, Prediabetes. Abnormal glucose or abnormal glucose tolerance without further provider confirmation of the disease should be assigned to code R73.09, Other abnormal glucose.

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Linking of Diabetes and Cellulitis

For coding a combine code for diabetes and Cellulitis, the provider must clearly mention that cellulitis as a diabetic skin complication. You cannot assume a causal relationship between diabetes and cellulitis.

When the causal relationship is unclear between diabetes and cellulitis, we need to query the provider regarding the relationship and whether cellulitis is a skin complication caused by the diabetes.

E11.628 Type 2 diabetes mellitus with other skin complications

Each scenario is different for every patient, hence the linkage and relationship between diabetes and cellulitis should be clearly documented by the provider. When there is doubt on whether a condition is a diabetic complication, you can query the provider, do not assume a relationship between them.  

Specific terms “with”, “due to” or “associated with” should be present for coding diabetes complications and diabetes. This will only give a strong causal relationship between diabetes and its associated condition.

Coding professionals should not assume a causal relationship when the diabetic complication is “NEC.” The ICD-10-CM classification presumes a cause and effect relationship with certain specific conditions when the Alphabetic Index links the conditions by the terms “with”, “due to” or “associated with”.