Welcome to our Provider Coding Blast! In these articles, we will be discussing best practices with documentation of specific diagnosis codes as well as any trends we are seeing with these conditions.
This month’s Blast will be covering the following topics: Diabetes, Chronic Kidney Disease, and Copy and Pasting of documentation.
Diabetes
Some key points to remember when seeing your patients with diabetes, especially if you see them only once a year. It is important to capture the following:
Evaluate their glycemic status (hemoglobin A1c [Hba1c] or glucose management indicator [GMI0]) was at the following levels during the year:
- Glycemic Status <8.0%
- Glycemic Status >9.0%
The NCQA reassessed how to identify individual with diabetes under these measures:
- Glycemic Status Assessment for Patients with Diabetes
- Blood Pressure Control for Patients with Diabetes
- Diabetic Eye Exam
- Kidney Evaluation for Patients with Diabetes (Blood and Urine testing)
- Statin Therapy for Patients with Diabetes
- Emergency Department Visits for Hypoglycemia in Older Adults with Diabetes
Does your office hand the member a sheet of paper regarding a diabetic eye exam with an email or a fax number the eye doctor’s office can return directly to you for your records?
If a patient is prescribed a diabetic-related medication for reasons unrelated to diabetes, please be sure to document the reason the patient is taking the medication!
Billing and Documentation Concerns
We recently reviewed some common conditions that are not always redocumented/rebilled on a face-to-face encounter with a patient. We want to remind everyone that not only does the diagnosis being recaptured assist us, but it also assists our other teams in our organization to ensure the member is receiving the best healthcare.
We reviewed Diabetes (HCC 18 and HCC 19) and Chronic Kidney Disease (HCC 136, HCC 137, and HCC 138).
Diabetes:
| HCC | HCC Description | Diagnosis |
| HCC 18 | Diabetes with chronic complications |
Type 1: E10.2x – E10.8 Type 2: E11.2x – E11.8 |
| HCC 19 | Diabetes without chronic complications |
Type 1: E10.9 Type 2: E11.9 |
When documenting diabetes conditions, make sure the documentation supports the diagnosis code billed. Specifically:
- Document the type of diabetes the patient has, Type I or Type 2. State whether it is controlled or uncontrolled. Please also refer to recent testing if applicable.
- Document the chronic complication(s) the patient may have, such as chronic kidney disease (CKD), nephropathy, retinopathy, etc.
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- Make sure to indicate the stage of the CKD, the location, and laterality if appcliable.
- Evaluate the chronic conditions. Indicate if they are still active, being treated, and who is treating the condition if not being treated by you.
- Document what medication or treatment is being used to manage their diabetic condition:
- Insulin (Z79.4)
- Oral antidiabetic or hypoglycemic drugs (Z79.84)
- Non-insulin injectables (Z79.899)
Documentation Best-Practice Examples:
Type 2 Diabetes Mellitus with CKD: Patient has type 2 DM, poorly controlled, continue current meds (make sure med list is up to date and accurate). CKD stage 3b, eGFR is 42. Return to office within 8 weeks for additional bloodwork.
Diagnosis codes to use:
| Diagnosis Code | Diagnosis Description |
| E11.22 | Type 2 diabetes mellitus with diabetic chronic kidney disease |
| N18.32 | Chronic kidney disease, stage 3b (late) |
Chronic Kidney Disease: When documenting CKD conditions, make sure the documentation states what stage of the disease the patient is in. Please also be sure to refer to the most recent testing done to support the code selection.
| Stage/Severity | GFR value/Description | ICD-10-CM-code |
| Stage 1 (Normal or High GFR) | GFR ≥ 90 ml/min/1.73 m2 | N18.1 |
| Stage 2 (Mild) | GFR 60-89 ml/min/1.73 m2 | N18.2 |
| Stage 3a | GFR 45-59 ml/min 1.73 m2 | N18.31 |
| Stage 3b | GFR 30-44 ml/min 1.73 m2 | N18.32 |
| Stage 4 (Severe) | GFR 15-29 ml/min 1.73m2 | N18.4 |
| Stage 5 (Kidney failure without dialysis) | GFR < 15 ml/min 1.73m2 | N18.5 |
| Stage 5 End Stage Renal Disease (ESRD) | ESRD: requiring chronic dialysis or transplantation | N18.6 |
| CKD Unspecified | Chronic Kidney Disease, unspecified | N18.9 |
Please note: ICD-10-CM guidelines state that CKD can be assumed “due to” both hypertension and diabetes, even in the absence of the provider linking them, unless the CKD is linked by a provider to another condition. The guidelines also state that the code for the stage of CKD is required.
How to avoid common pitfalls with documenting CKD:
- State whether CKD is acute or chronic.
- Make sure to document the stage of the CKD and reference the latest testing.
- If an underlying condition is present, be sure to document what the underlying condition is and how it affects the CKD.
- Specify any complications the patient is experiencing.
- Avoid documenting renal insufficiency.
2024 Code Recapture of Diabetes and Chronic Kidney Disease
Data is current as of June 30, 2024.
Every year, HCC 18 or 19 should be redocumented. As we are nearing the end 2024, we see there is still a deficit with not capturing the diabetic diagnosis codes or HCC 18. This is very concerning to us as well as the overall care of the patient.
Please make sure your diabetic patients are being seen on a routine basis.
Chronic Kidney Disease:
Data is current as of June 30, 2024.
Again, as we are nearing the end of 2024, we can see that there are many opportunities to recapture the member’s CKD. If the condition has resolved that is one thing, but we see that there is 30% of our member population that needs to have this condition reevaluated and documented.