day2pp5 diabetic complications pinson final - rdp 102618 ... · title: microsoft powerpoint -...

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Diabetic Complications: Diagnosis, Documentation, Coding, and Compliance

Richard D. Pinson, MD, FACP, CCSPrincipal and Medical DirectorPinson and Tang, LLCCDI Educators and ConsultantsHouston, TX

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Learning Objectives

At the completion of this educational activity, the learner will be able to:

• Explain the regulatory requirements for coding HCCs

• Recognize the diabetic complications that affect risk adjustment

• Identify diagnostic criteria for diabetic complications

2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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Richard Pinson, MD, FACP, CCS

• Physician, educator, and healthcare consultant

• Practiced internal medicine and emergency medicine for 25 years

• Trained thousands of physicians, documentation specialists, and coders nationwide

• Coauthor of the CDI Pocket Guide, the Outpatient CDI Pocket Guide: Focusing on HCCs, and the Pocket Guide for Coding Professionals

• Author of monthly “Coding Corner” column for the American College of Physicians’ ACP Hospitalist magazine for over 8 years

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Agenda

1. Introduction to HCCs

2. Outpatient Coding Guidelines

3. CMS billing requirements

4. Diabetic complications

HyperglycemiaHypoglycemiaArthropathyCirculatory HyperlipidemiaKidney

NeuropathyOralOsteomyelitisRetinopathy/ocularSkin


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What Are HCCs?

• HCCs are designed to group patients that are clinically similar and with similar long‐term costs

• Large majority are chronic conditions

• Captured in both inpatient and office settings

• Used as both a paymentmethodology and a diagnostic classification for risk adjustment

• 2 sets of HCCs:

– 83 CMS‐HCCs for Medicare Advantage plans

– 115 HHS‐HCCs for ACA plans

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Inpatient vs. Physician Practice

• Long visit

• Payment based on diagnosis/DRG

• Inpatient coding guidelines

• Documentation requirements

– Meet OCG Section III secondary diagnosis guideline

• Short visit

• Payment based on E/M level, not diagnosis

• Outpatient coding guidelines

• Documentation requirements

– OCG Section IV: Must be relevant to encounter and addressed during the visit

Inpatient Physician practice


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Official Coding Guidelines

• InpatientOCG Section III – Definition of Additional Diagnosis: clinical evaluation, treatment, diagnostic procedures, increased nursing care/monitoring, or extended LOS.

• OutpatientOCG Section IV – Documented condition must be directly “relevant” to or “affect” the specific encounter. The term “addressed” best describes this requirement.

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Official Coding Guidelines: Outpatient

• Section II, Principal Diagnosis and Section III, Other (Secondary) Diagnoses do not apply to outpatient– For inpatient only

– Section I, Conventions / General and Chapter‐Specific Guidelines does apply to both outpatient and inpatient

• IV.I: “Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patientreceives treatment and care for the condition(s).”

• IV.J: “Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.”


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Official Coding Guidelines: “With”

• Section I.A.15– The classification presumes a causal relationship between two

conditions linked by “with” or “in” 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

• Coding Clinic, 2nd Quarter 2018, p. 6– The “with” guideline does not apply to any term listed in the Index

as NEC (not elsewhere classified)– Assume a causal relationship for any term listed as “with” but no

NEC designation

• Examples:– Linked: Diabetes type 2 with osteomyelitis (E11.69) – Not linked: Diabetes type 2 with arthropathy NEC (E11.618)

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Key Chronic HCC Diagnoses

• Abdominal aortic aneurysm, aortic atherosclerosis

• Alcohol/drug abuse, dependence

• Amputation status

• Cardiac dysrhythmia

• Cardiomyopathy

• Chronic kidney disease

• Chronic respiratory failure

• COPD

• Depression

• Diabetic complications

• Heart failure

• Morbid obesity/BMI

• Paralysis (plegia/paresis)

• Malnutrition

• Neoplasms

• Pulmonary hypertension & heart disease

• Skin ulcers


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Diagnosis of Diabetes

• HbA1c > 6.5%, or

• FBS > 125 mg/dl, or

• 2‐hour OGGT > 200 mg/dl, or

• Random glucose > 200 mg/dl + symptoms

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Types of Diabetes

• Type 1 (E10) – “juvenile”; deficient insulin production

• Type 2 (E11) – “adult”; peripheral insulin resistance high insulin production islet cell “burnout”

• Underlying medical condition (E08) – cystic fibrosis, chronic pancreatitis, others

• Drugs/chemical toxins (E09) – steroids; dioxin pesticide

• Other specified (E13) – e.g., genetic deficiencies; post‐procedural; Type 1.5

• Pregnancy (O24) – gestational or preexisting by type


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Diabetic Complications

• Acute (HCC 17 – 0.307)– Hyperglycemia

– Hypoglycemia

– Ketoacidosis (DKA)

– Hyperglycemic hyperosmolar state (HHS)

• Chronic (HCC 18 – 0.307)– Arthropathy

– Circulatory complications

– Hyperlipidemia

– Kidney complications

– Neuropathy

– Oral

– Osteomyelitis

– Retinopathy/ocular

– Skin

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Hyperglycemia (E11.65)

• Blood sugar > 140 mg/dl

• Very common during outpatient visits

• Documentation terminology– Hyperglycemia

– High or elevated blood sugar

– Poorly controlled

– Inadequately controlled

– Out of control

• “Uncontrolled” – clarify if hypo‐ or hyperglycemia (ICD‐10‐CM Index)

• See also Coding Clinic, First Quarter 2016, p. 42


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Hypoglycemia (E11.64‐)

• Blood sugar < 70 mg/dl

– Coding requires some sort of intervention

– Symptoms unusual if > 50 mg/dl

• With or without coma (unexpected in outpatient setting)

• Documentation terminology

– Hypoglycemia

– Low blood sugar

– Uncontrolled?

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Arthropathy (E11.61‐)

• Diabetic neuropathic arthropathy (“Charcot joint”) – Automatically linked

– Chronic, progressive destruction of joint

– Due to absent sensation (sensory neuropathy)

– Repetitive, unrecognized joint injury

– Primarily foot and ankle

• Other types – must be specified as diabetic– Adhesive capsulitis (frozen shoulder)

• Painful, decrease in ROM without a known intrinsic shoulder disorder

– Calcific periarthritis (calcific tendinitis)

• Severe pain, sometimes with stiffness, occurring spontaneously usually in the morning

• X‐ray: periarticular calcifications

• Cause unclear


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Circulatory Complications (E11.5‐)

• Peripheral vascular/artery disease (PVD/PAD)– Atherosclerosis (arteriosclerosis) is the causative process– Lower extremities only

• Upper extremities extremely unusual• Not “central” arteries: coronary, carotid, aortic, renal, mesenteric

– With or without gangrene– Automatically linked

• Coding Clinic, 2nd Quarter 2018, p. 7

• Microangiopathy– Damage to small vessel and capillary endothelium– Contributes to retinopathy, neuropathy, nephropathy,

atherosclerosis, ischemic ulcers– Automatically linked

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Hyperlipidemia

• Diabetic hyperlipidemia has unique characteristics:– Hypertriglyceridemia– Low HDL cholesterol– LDL cholesterol not particularly elevated

• Clinical indicators: – Triglycerides (fasting) > 200 mg/dl

• Severe > 500 mg/dl• Sometimes several thousand mg/dl with “lipemic” (cloudy) serum

– HDL cholesterol < 40 mg/dl

• Coded E11.69 (other specified) + E78.5 (hyperlipidemia)

– Must be specified as diabetic


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Hyperlipidemia

• Treatment to lower triglycerides:– Low fat, diabetic diet; avoid alcohol

– Fibrates – also increase HDL

• Gemfibrozil (Lopid)

• Fenofibrate (multiple brands)

– Niacin > 1,500 mg/day – also increases HDL

– Omega‐3 fatty acids (fish oil) ≥ 4 gm/day

– Occasionally statin drugs in very high doses for modest hyper‐triglyceridemia (not primarily for LDL cholesterol)

• Clinical validation– Common documentation/coding error

– Most of the common forms of hyperlipidemia are associated with hypercholesterolemia (elevated LDLs) without significant hypertriglyceridemia

– Vast majority of diabetic patients with hyperlipidemia do not have diabetic hyperlipidemia

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Kidney Complications (E11.2‐)

• Diabetic nephropathy– Automatically linked– Documentation terminology

• Nephropathy• Kimmelstiel‐Wilson disease• Intercapillary glomerulosclerosis• Intracapillary glomerulonephrosis

– Specific diabetic renal diseases causing CKD stages 1–5

• Chronic kidney disease (CKD)– Automatically linked– Include stage

CKD stage GFRStage 1* >90

Stage 2* 60‐89

Stage 3 30‐59

Stage 4 (CC) 15‐29

Stage 5 (CC) < 15

ESRD (MCC) N/A

*Requires the presence of certain kidney damage markers (very common in diabetes)


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Neuropathy (E11.4‐)

• Autonomic– GI: gastroparesis, GERD, chronic diarrhea or constipation– CV: orthostatic hypotension with or without syncope, resting

tachycardia, exercise intolerance– GU: bladder dysfunction, erectile dysfunction– Sleep apnea

• Sensory‐motor peripheral neuropathy:– Pain, numbness, loss of touch sensation, reflexes decreased or

absent, muscle weakness if severe– Mono = one limb or one nerve– Poly = multiple nerves in multiple limbs– Unspecified usually refers to polyneuropathy, but clarification not

required– Cranial mononeuropathy – e.g., ocular muscles, Bell’s palsy

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Neuropathy (E11.4‐)

• Automatically linked terminology:– Neuropathy– Mononeuropathy– Polyneuropathy– Autonomic (poly) neuropathy– Gastroparesis– Neuralgia– Amyotrophy


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Oral Complications (E11.63‐)

• Periodontal disease (E11.630)– Common diabetic complication– Automatically linked– Includes periodontitis and gingivitis

• Diabetic dry mouth:– Common diabetic complication– Often causes: multiple cavities, periodontal disease, and oral candidiasis

– Must be specified as diabetic• Coded E11.638 (other oral complication NEC) + R68.2 (dry mouth)

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Osteomyelitis (E11.69)

• Primarily caused by deep diabetic ulcer (hematogenous spread very unusual)

• Automatically linked (specifically listed without “NEC” in Index)

• Coded E11.69 (other specified complication) + a code from M86 (osteomyelitis)


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Retinopathy (E11.4‐)

• Automatically linked:– Retinopathy, unspecified– Proliferative– Nonproliferative– Macular edema

• Cataract– Ocular manifestation not directly related to retinopathy– Automatically linked

• Diabetic glaucoma– Ocular manifestation not directly related to retinopathy– Must be specified as diabetic

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Skin Complications (E11.62‐)

• Diabetic dermatitis (E11.620)– Appears that a skin condition described as “dermatitis” is

automatically linked to diabetes unless another cause is specified by the provider• Not listed “NEC” by Index

– Many types of dermatitis have other specific causes, e.g., atopic and contact dermatitis are allergic in nature• Consider clarification of “dermatitis” that is not clearly related to diabetes

– Necrobiosis lipoidica is automatically linked to diabetes

• Foot ulcer (E11.621)– Automatically linked– Use additional code to identify location– Clarify if heel ulcer (usually non‐diabetic pressure ulcer but does

suggest peripheral neuropathy)


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Skin Complications (E11.62‐)

• Other non‐pressure ulcer (E11.622)– Must be specified as diabetic

– Use additional code to identify location

– Clarify if appears to be pressure ulcer (e.g., heel), which suggests peripheral neuropathy

• Other diabetic skin complication NEC (E11.628)– Must be specified as diabetic– Use additional code for the specific complication– Common diabetic skin complications:

• Granuloma annulare – circular clusters of reddish/brown spots usually on hands and feet

• Diabetic dermopathy – dull red papules that progress to small, round, atrophic hyperpigmented skin lesions usually on the shins

• Eruptive xanthomatosis – due to severe hyperlipidemia; firm, yellow, pruritic bumps with surrounding red halos

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Thank you. Questions?

Richard Pinson ‐ [email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.


day2pp5 diabetic complications pinson final - rdp 102618 ... · title: microsoft powerpoint -...

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