Cracking the Code

Diabetes with Long-term Insulin and Oral Medications

The ICD-10-CM Official Guidelines for Coding and Reporting has specific instructions pertaining to correctly reporting long term use of insulin and oral hypoglycemics. When a provider documents that a patient receives long term insulin or oral medications, it is appropriate to report either Z79.4, long-term (current) use of insulin or Z79.84, long-term (current) use of oral hypoglycemic drugs. However, when the provider documents that a patient receives both insulin and oral medications, it is appropriate to ONLY report a diagnosis code for the long-term use of insulin. It is important for coders to remember this guidance to prevent unnecessary errors when reporting all final secondary diagnoses.

Reference: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 Section I.C.4.a.3. and AHA Coding Clinic Third Quarter 2019, page 37: Chapter 4: Endocrine, nutritional, and metabolic disease (E00-E89)
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