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When can E11.8 be coded?

drksingh

Contributor
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Hello AAPC Coding members,

I am having a hard time finding a reason to code for E11.8. This emerged from a conversation with a fellow Provider who is a coder (in his world). His explanation was whenever there is a complicated DM type 2 patient who is on the Metformin with or w/o insulin, he would put E11.8 as DM2 with complications, followed by Z79.84 for Long term (current) use of oral hypoglycemic drugs or the Z79.4 for use of insulin. I was amazed. His explanation was that DM2 patients do have complications and the code allows him to get by and yet achieve the HCC status if there is no specific complication to point to but he believes the patient is complicated otherwise.

In my search, I cannot find a good reason to code for E11.8, because if the provider noticed a complication of DM, you will notate in the medical record e.g. neuropathy, hyperglycemia, poor-control, etc.

So my question is - In what scenario will really E11.8 be worth coding for?

Looking for some amazing answers or scenarios. Thanks in advance.
 

sls314

Guru
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I would caution against using E11.8 as a general code for all diabetic patients who don't have a more specific code to assign. If a provider routinely used that code, it would likely be a red flag and not stand up to an HCC audit. It's not a good idea from a compliance standpoint.

In the book Risk Adjustment Coding and Documentation by Sheri Poe Bernard, she says:

"Be very cautious in reporting codes E--.8" then she goes on to say " Any support in the record for a complication of diabetes would likely identify the complication, and a more specific code would be indicated. Without any support of the 'complication', the validity of the HCC may be called into question. This is a topic worthy of an internal coding policy within individual organizations."

I review HCC codes for a large physician group prior to the claim being billed. If I don't see reasonable support for E11.8, I convert it to E11.9 before the bill even goes out. (I should note that I rarely even see E11.8 come through, so it's very rare that I'd have to do that.)
 

thomas7331

True Blue
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I agree with you both here. The meaning of 'complications', in this context, is a secondary disease or clinical manifestation that has been cause by the diabetes - it does not mean that the patient's diabetes is complicated to treat. In other words, these are complications for the patient - not for the provider. 'Difficult to manage' or 'difficult to treat' is not a medical complication of a disease. It would be unusual for a provider to documentation that the patient's disease has caused complications yet not have indications anywhere in the record of what those complications are, and I can't even think think of a time that I've come across a record where I've needed to use the E11.8 code.
 

drksingh

Contributor
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Thank you!

E11.69 is another one that gives headaches. NOt sure why everyone misinterprets the 'with' guideline to their own convenience. I rather have the provider notate in a simple language that the DM has caused this particular complication or simply say that patient has both DM and the complication because of long-term DM.
 
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