Cracking the Code
ICD-10-CM Guidelines for Diabetes
Per FY 2021 ICD-10-CM Guidelines for Coding and Reporting, there is updated information in the section pertaining to the chapter specific guidelines for coding diabetes mellitus. This information can be reviewed under section I.C.4.a.3. titled “Diabetes mellitus and the use of insulin, oral hypoglycemics, and injectable non-insulin drugs” and section I.C.4.a.6. titled “Secondary diabetes mellitus”.
“If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11-, Type 2 diabetes mellitus, should be assigned. An additional code should be assigned from category Z79 to identify the long-term (current) use of insulin or oral hypoglycemic drugs. If the patient is treated with both oral medications and insulin, only the code for long-term (current) use of insulin should be assigned. If the patient is treated with both insulin and an injectable non-insulin antidiabetic drug, assign codes Z79.4, Long-term (current) use of insulin, and Z79.899, Other long term (current) drug therapy. If the patient is treated with both oral hypoglycemic drugs and an injectable non-insulin antidiabetic drug, assign codes Z79.84, Long-term (current) use of oral hypoglycemic drugs, and Z79.899, Other long-term (current) drug therapy. Code Z79.4 should not be assigned if insulin is given temporarily to bring a type 2 patient’s blood sugar under control during an encounter.”