E08.69, E09.69, E10.69, E11.69, E13.69 Diabetes with other specified complication
HCC 18 (0.302 ); RxHCC 30 (0.408)
vs.
E08.9, E09.9, E10,9, E11.9, E13.9 Diabetes, uncomplicated
HCC 19 (0.105); RxHCC 31 (0.270)
CLINICAL BACKGROUND
Diabetes may cause complications of diabetes. Most complications have specific codes, for example, diabetic retinopathy, nephropathy or neuropathy. For instances in which there is no specific code, Exx.69 is reported with a second code identifying the complication. The most common accepted complication that does not have a unique code is osteomyelitis, a bone infection in the foot.
WHAT’S THE PROBLEM?
There are three issues with how this is being used.
(1) For cases of other specified diabetic complications, the diabetes must be explicitly linked to the complication, based on ICD-10-CM guidelines, using words like “diabetic XX” or “XX due to diabetes” or “XX secondary to diabetes.” The code that links XX to diabetes is often being reported without the explicit causal language currently, and may fail an audit;
(2) The code description (e.g., Type 2 diabetes with other specified complication) is being documented in lieu of language that actually specifies the complication and will fail an audit; and
(3) Providers are being trained to link diabetes to diagnoses that have a dubious relationship to diabetes, for example, morbid obesity due to diabetes (morbid obesity may cause diabetes, but not the inverse) or diabetic hyperlipidemia (high lipids are considered a risk for diabetes, not the inverse). In both cases, diabetic control and general health may be improved if the other condition is reduced, but the condition itself is not a manifestation of the diabetes. These cases may fail clinical validation.
Osteomyelitis is one diagnosis that the ICD-10-CM Index classifies as a manifestation of diabetes that should be reported with the “other specified diabetes” codes. In Medicare fee-for-service data from 2019, only two percent of claims reporting diabetes with other specified complications also reported osteomyelitis. In eight percent of the cases, there were no secondary diagnoses at all, and therefore no identification of the specific complications leading to that code choice. In 26% of the cases, the secondary diagnoses were disorders that, while affecting diabetes, are not supported in the scientific community as being caused by diabetes: metabolic syndrome X, obesity, hypercholesteremia and other lipid disorders, and hypertension, for example.
The Granite GRC Consulting team is standing by to help. Connect our team at SPB@granitegrcconsulting.com to set up a consultation.
Granite GRC Consulting has a risk adjustment team that can identify outliers and fine-tune risk adjustment processes for providers, payers, and third-party auditing companies. The Granite GRC risk adjustment team includes Sheri Poe Bernard, CRC, CDEO, CCS-P, CPC (coding), Khush Singh, MD, MHA, CPC, CRC, CPMA, CPCO, CDIP (clinical and operational compliance), and Tia Goss Sawhney, DrPH, FSA, MAAA (actuary and data analytics). For more information go to: https://granitegrcconsulting.com/