Ensuring use of the correct diagnosis code is essential when coding for the ophthalmic complications that can arise from diabetes mellitus (DM). If numbers are accidentally transposed on an ICD-10 code, it reports a completely different diagnosis. This month’s column answers a few common questions.
Q: What ICD-10 codes are used for DM with ophthalmic complications?
A: The ICD-10 codes depend on the type of DM, presence of complications, and laterality. There are 5 code options, depending on the kind of DM that the patient has:
- E08.3xxx DM due to underlying condition with ophthalmic complications
- E09.3xxx Drug or chemical induced DM with ophthalmic complications
- E10.3xxx Type 1 DM with
ophthalmic complications - E11.3xxx Type 2 DM with
ophthalmic complications - E13.3xxx Other specified DM with ophthalmic complications
The fourth character, 3, indicates ophthalmic complications. The fifth, sixth, and seventh characters—represented in the example above by x placeholders—allow the complication to be specified in greater detail.
Q: What do the fifth, sixth, and seventh characters represent in the ICD-10 codes?
A: Building on the information above, the fifth, sixth, and seventh characters are used to further specify the ophthalmic complication. The fifth character indicates the specific form of diabetic retinopathy (DR): unspecified (1); mild (2), moderate (3), or severe (4) nonproliferative DR; or proliferative DR (5). The sixth character denotes the absence (9) or presence (1) of macular edema (ME). Finally, the seventh character specifies laterality—identifying whether the condition affects the right eye (1), left eye (2), both eyes (3), or if the eye is unspecified (9).
For example, a patient with type 2 DM (E11.3) with mild nonproliferative DR (2) and ME (1) in her right eye (1) would be coded E11.3211. If that same patient did not have ME in the right eye, the appropriate code would be E11.3291.
Q: What ICD-10 code should be used for proliferative DR?
A: A type 2 DM patient with proliferative DR would be coded E11.35xx. Additional sixth character codes are available to provide greater specificity for proliferative DR cases. These are: With macular edema (1); With traction retinal detachment (TRD) involving the macula (2); With TRD not involving the macula (3); with combined TRD and rhegmatogenous retinal detachment (4); Stable proliferative DR (5); and without ME (9).
Select the appropriate ICD-10 code for PDR depending on whether there is a secondary ophthalmic manifestation or if it is stable.
Q: How should diabetic macular edema (DME) be coded?
A: DME is included in the codes for diabetic retinopathy; it is not coded separately. For example, a patient with type 2 DM and severe nonproliferative DR with ME in the right eye would be coded E11.3411.
Cases that resolve following treatment are coded E11.37xx, with the sixth and seventh characters that are appropriate for the situation.
Q: How do you code for a diabetic patient with no complications?
A: Use the appropriate diabetes mellitus code without the “.3” extension, such as:
- E08.9 DM due to underlying condition without complications
- E09.9 Drug or chemical induced DM without complications
- E10.9 Type 1 DM without
complications - E11.9 Type 2 DM without
complications - E13.9 Other specified DM
without complications
Physicians ensure accurate claims are submitted by paying attention to the ICD-10 details for DM with ophthalmic complications and selecting the proper diagnosis code with the highest specificity. RP
