Note from the Instructor: Diabetes documentation, a CDI quick tip

By Allen Frady, RN, BSN, CCDS, CCS, CRC           

In following ACDIS’ blogs and discussion strings, you can easily count which topics which receive the lion’s share of attention on one hand. Encephalopathy, malnutrition, sepsis, myocardial infarction, and respiratory failure. Rinse, repeat, and discus these same five again.

By now you might think we would all be more or less experts on these most controversial of documentation improvement topics. These conditions, however, are highly nuanced, extremely complex, and usually more gray than black-and-white so fear not: I promise you will continue to hear about these as we move forward.

Nonetheless, I thought I would write something on a different diagnosis. Enter today’s quick tip: Diabetes. Is that number six on the most frequently discussed diagnoses?

Diabetes is not getting enough attention. When reviewing the record of a diabetic, try to remove yourself from the individual words being used in the documentation to get an impression regarding the overall presentation and care of a patient who would be best described as a “vascular admission,” a “renal admission,” a “neuro admission,” or an “endocrine admission.”  

If the admission is best represented as a vascular admission for example, but the documentation is mostly reporting the neuropathy or general diabetic issues (such as osteomyelitis or poorly controlled sugars), then your vascular admission has a high likelihood of being reported as a general endocrine admission. As a CDI specialist, I would say you have work to do on this case. Sure, all the linkages are going to be assumed with the new coding rules, but the sequencing of the principle diagnosis is going to drive the diagnosis directly into a DRG that does not best represent the clinical situation.

For review, remember these following quick rules of thumb.

• If the principle diagnosis is E11.29, diabetes with other diabetic kidney disease, the admission will be categorized as a renal admission (DRG 700)
• If the principle diagnosis is E11.43, diabetic autonomic neuropathy (which can be the principal diagnosis with diabetic gastroparesis), then the admission falls in the neuro category (DRG 074) “cranial and peripheral nerve disorders”
• If you sequence diabetes with foot ulcer (E11.621) as the principle diagnosis, then you will categorize the patient as an endocrine admission (DRG 639) as the DRG is just “Diabetes”

Wouldn’t you know it? If you sequence “diabetic osteomyelitis” as the principle diagnosis you get ICD-10 Code E11.69 and still classify the patient as an endocrine patient.  

What if the care is not really directed at the diabetes at all? What if the care is focused on maximizing circulation and wound healing because the patient has diabetic peripheral angiopathy? Rather than blindly sequencing the codes based on the order the physician listed them or the feeling the coder got from the fact that “diabetic foot” and “diabetic osteomyelitis” was listed throughout the chart, I would argue that the principle diagnosis and DRG should actually be ICD-10 code E11.51 (or one close to it) and DRG 301 “Peripheral vascular disorders.” Why? Because it is a wound/vascular admission, not an endocrine admission.

Let’s make it even more nuanced. Suppose the wound came from limb neglect because the patient had severe neuropathy which resulted in the patient allowing a small wound to become an ulcer? For me, this can go either way. While the underlying etiology should result in ICD-10 code E11.42 and DRG 074 “Cranial and peripheral nerve disorders,” it can be argued that neuropathy is not really ever addressed in the short term acute inpatient setting for patients with diabetic polyneuropathy and the care is focused on wound healing and preventing infection (sometimes amputation). For this reason, I am somewhat ambivalent about how these patients should be categorized in the DRG. Perhaps we should view them as “Endocrine” admissions.  

I would argue in many cases, however, that the circulatory compromise which undoubtedly contributed to the ulcer not healing would still drive the DRG to a better clinical match of DRG 301 “Peripheral vascular disorders.” Using the diabetic circulatory impairment also better fits with the debridements, amputations, and wound infections. It better explains the underlying etiology of the non-healing ulcer which eventually lead to the osteomyelitis and it better explains the outcome which is often, more amputations. Yet amazingly, I often do not even see the diabetic vascular compromised documented anywhere in the record in cases where there is clearly some circulatory compromise.

I think by now you get the point. When teaching this section in class, I have long sensed disinterest in my CDI students. I believe many see it is as the purview of the physician and coder without much need for documentation intervention. This is exacerbated tenfold once the new “with” coding guidelines. Perhaps even worse, I often get the impression from students that many trainees just do not care about the sequencing and assigned DRG for various diabetic scenarios. It appears they see it as a lost battle, out of their control, or possibly not worth their time.

Pay attention to meaning behind the overall admission. Ask yourself, what was the underlying etiology, truly? Not what is documented, but what it most likely directly contributing to the presentation. Ask yourself what diagnosis beyond “diabetes” is being treated. Not just diabetes, but exactly what manifestation? Is that particular diabetic manifestation going to be correctly sequenced as the principle diagnosis the way the physician is documenting it in the record? Quite frequently, the answer to that is an emphatic “no.”

In the end, it’s up to you, the CDI specialist. If you’re okay with your neurological, renal, and vascular patients all being categorized as endocrine admissions, then who am I to complain? No, seriously, take an interest in this issue. It drives us OCD people crazy!

Editor’s note: Frady is a CDI education specialist for HCPro in Middleton, Massachusetts. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps, visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.