Question Coding for unstable type 2 diabetes mellitus

twizzle

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I have a provider who documented 'unstable type 2 diabetes, improving (HbA1c has come down from 9.2 to 8.8). Start on new meds as prescribed'.

I was auditing a coder who used E11.9 (type 2 DM without complications) which I said was incorrect. I recommended E11.8 (type 2 DM with unspecified complications). We can't code E11.65 because, despite the high HbA1c we can't make the clinical determination that the patient has hyperglycemia.

I was told that E11.9 is correct which I strongly disagree with. Anyone encountered this scenario and how did you code it? I can't find anything online pertaining to how to code unstable type 2 DM.
 

Kristen Bensel

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I have been told that in situations like this, E11.9 would be considered appropriate as the patient doesn't have any complications from the high A1C. In fact, they documented that it is improved. If there is no documentation of a complication(s), it seems inappropriate to code the E11.8.
However, if there was any documentation in the note that indicated there might be complications that didn't get added in the assessment, I would discuss it with the provider and possibly have them amend the note.
 

thomas7331

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I would agree with Kristen here that E11.9 is the most appropriate code. 'Unstable' is not synonymous with 'complication', and there is no alphabetic entry in ICD-10 to direct a coder to E11.8 or any other code for documentation of 'unstable' in the diabetes section.
 

twizzle

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I appreciate the responses and can see where everyone is coming from. If you Google unstable diabetes though it says that it is "Unstable diabetes: A type of diabetes when a person's blood glucose (sugar) level often swings quickly from high to low and from low to high.

This sounds like a complication to me, particularly because the provider is having to add new meds to try to stabilize the problem.

Stay well.
 

fwnewbie

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Abnormal blood sugar is a symptom of diabetes, not a complication. A complication would be kidney damage, loss of vision, sepsis, etc that is due to the high blood sugar.
 

twizzle

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Hyperglycemia is a complication, hypoglycemia is a complication so I reckon quick swings between the two are also complications. Just my thoughts..

I get what you say about kidney damage, eye problems, neuropathy etc, and I think at the end of the day the provider isn't really meaning 'unstable' per the true medical descriptor, more that the blood sugar is still too high. If only he had said 'hyperglycemia' which is clearly the case based on the HbA1c, everything would have been so much easier. At least it illustrates why CDI is so important.

Thank you everyone for your input.
 

thomas7331

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Just an additional thought to add here - though I personally would still go with E11.9 on this, there are legitimate reasons, as you've argued, that this could be coded either way. In my opinion, I think in our field we too often get into a mind-set where there are only 'right' or 'wrong' codes and I think this is a mistaken approach. The difference between E11.8 and E11.9, in a case like this, is very subtle and unless these codes are on a high-cost inpatient DRG claim, it is very unlikely to make any difference in payment or reporting one way of the other. I've advocated that coding auditors create a category of audit findings called 'variances' rather than 'errors' for such cases because different providers and coders will often make judgments in the grey areas that result in different codes and they shouldn't be penalized for this, nor should we unnecessarily drain resources from our already over-taxed healthcare system by overthinking these. I think this case is a good example of where considering this a 'variance' rather than an 'error' would be the best approach.
 

fwnewbie

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Just an additional thought to add here - though I personally would still go with E11.9 on this, there are legitimate reasons, as you've argued, that this could be coded either way. In my opinion, I think in our field we too often get into a mind-set where there are only 'right' or 'wrong' codes and I think this is a mistaken approach. The difference between E11.8 and E11.9, in a case like this, is very subtle and unless these codes are on a high-cost inpatient DRG claim, it is very unlikely to make any difference in payment or reporting one way of the other. I've advocated that coding auditors create a category of audit findings called 'variances' rather than 'errors' for such cases because different providers and coders will often make judgments in the grey areas that result in different codes and they shouldn't be penalized for this, nor should we unnecessarily drain resources from our already over-taxed healthcare system by overthinking these. I think this case is a good example of where considering this a 'variance' rather than an 'error' would be the best approach.
I agree with the overthinking and right or wrong codes, but this is what comes from the type of education that insists on a narrow definition for each scenario or no credit given. However, I like seeing the thought processes as coders consider the pathophysiology of disease processes. Kudos to Twizzle for being knowledgeable enough to search for an answer!
 

fwnewbie

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I also questioned the "....without complication" option when working a scenario for a smoker. Can't remember all the details but how can a chronic smoker not have complications? I mean, their breathing is affected, there is usually a phlegmy cough not present in a healthy person. So how is "complication" defined?
Sorry to post this, but I can't get into my Practicode and I'm going slightly nuts sitting here. Maybe I'll just go work on my knitting! :D
 

thomas7331

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I also questioned the "....without complication" option when working a scenario for a smoker. Can't remember all the details but how can a chronic smoker not have complications? I mean, their breathing is affected, there is usually a phlegmy cough not present in a healthy person. So how is "complication" defined?
Sorry to post this, but I can't get into my Practicode and I'm going slightly nuts sitting here. Maybe I'll just go work on my knitting! :D
For coding purposes, 'complication' (like any other term) has to be defined by the provider, unless there is an official guideline or other source used by your organization, payers or auditors that qualifies it. The fact is that in the case of smoking, while most providers will record a patient's smoking history, they won't usually document that the patient's conditions are a complication or are due to the smoking, even though they most likely are. Which again is why, in a situation like the above, I wouldn't fault a coder for sticking to the verbiage in a provider's note and not assigning codes based on definitions or interpretations that have a source outside of what is actually in the note itself. If it is a critical piece of information and the documentation is not clear, though, then a query to the provider should put the question to rest.
 
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