AHA Coding Clinic 3rd Quarter 2018 – Key Highlights

Below are highlights from Coding Clinic 3rd Quarter 2018 (effective with discharges starting September 24th).

Diabetes with necrotic pressure ulcer, diabetic peripheral vascular disease and neuropathy  

  • If a provider documents an association between diabetes and a pressure ulcer due to gangrene, the principal diagnosis is gangrene
  • The “code first” note under category L89, pressure ulcer, directs coders to assign the underlying cause, which in this case is the gangrene
  • Even though the pressure ulcer is linked to diabetes, since diabetes may increase the risk of pressure ulcers, the principal diagnosis remains the gangrene since it is the underlying cause of the pressure ulcer
  • Pressure ulcers typically form near bony prominences such as the elbows, tailbone, and heels
  • Diabetic ulcers typically involve the feet starting at the toes and move upward due to the lack of circulation from peripheral vascular disease
  • So, whenever a diabetic patient with a history of peripheral vascular disease and neuropathy presents with ulcers/gangrene ensure the documentation is clear as to the etiology of the ulcers
  • Selection of the principal diagnosis will be driven by whether the provider documents “diabetic ulcer” or “pressure ulcer” (even if there are linking statements between the pressure ulcers and diabetes)
  • The location of the ulcer (e.g. toe vs heel) will provide a clue as to whether an ulcer is due to diabetes or pressure

Type 1.5 Diabetes Mellitus

  • Assign codes from category E13, Other specified diabetes mellitus, for type 1.5 diabetes mellitus
  • Type 1.5 diabetes is a form of diabetes in which an adult has features of both type 1 and type 2 diabetes
  • Individuals demonstrate both the autoimmune destruction of beta cells of type 1 diabetes and the insulin resistance characteristic of type 2 diabetes

Gastrointestinal Bleeding due to Multiple Possible Sources

  • Additional examples were included in this issue of Coding Clinic reiterating the rule that gastrointestinal hemorrhages and conditions such as diverticulosis and angiodysplasia do not require a due to/linking statement from the provider to assign a combination code for bleeding
  • For example, if a patient is admitted with hematochezia and undergoes a colonoscopy and is found to have sigmoid diverticulosis and colonic angiodysplasia, assign K57.31, diverticulosis of large intestine without perforation or abscess with bleeding, and K55.21, angiodysplasia of colon with hemorrhage
  • Per Coding Clinic, “the fact that bleeding is not seen during colonoscopy does not preclude the assignment of code describing hemorrhage”
  • Either condition can be sequenced as principal diagnosis

Chronic Atrial Fibrillation with Rapid Ventricular Response (RVR)

  • Assign I48.2, Chronic atrial fibrillation only, RVR is not coded separately


  1. AHA Coding Clinic – 3rd Quarter 2018

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