Complete, clear and consistent documentation is crucial for on-time reimbursement. Just as any other specialty, endocrinologists’ reimbursement is based on the documentation in the medical record. Endocrinology medical coding involves assigning the accurate diagnosis and procedure codes to various conditions and treatment procedures. It is crucial to submit the appropriate codes and modifiers for services rendered.
With the updated medical terminology, and more comprehensive classifications of diseases, combination codes for conditions & common symptoms or manifestations and inclusion of trimesters, ICD-10 codes help endocrinologists to clearly document the patient’s condition and specify the service provided.
Appropriate clinical documentation can – improve communication and collaboration between physician and the patient; provide an accurate representation of the severity and complexity of a patient’s illness; improve the quality of patient care; enable referring to the medical record together for problems, assessments, procedures and treatments; support and supplement provider documentation, and help substantiate the level of specificity required within ICD-10.
Common Endocrine Conditions and Their ICD-10 Codes
Adrenal Disorders
To properly code a neoplasm it is necessary to determine from the record if the neoplasm is benign, in situ, malignant, or of uncertain histologic behavior. For multiple neoplasms of the same site that are not contiguous, codes for each site should be assigned. Here are some examples.
- 01 Malignant neoplasm of cortex of right adrenal gland
- 10 Malignant neoplasm of medulla of unspecified adrenal gland
- 12 Malignant neoplasm of medulla of left adrenal gland
- 91 Malignant neoplasm of unspecified part of right adrenal gland
- 92 Malignant neoplasm of unspecified part of left adrenal gland
- 10 Neoplasm of uncertain behavior of unspecified adrenal gland
- 2 Neoplasm of uncertain behavior of parathyroid gland
Diabetes Mellitus
Using ICD-10 coding system, diabetes mellitus can be classified by type, hyperglycemia or hypoglycemia as well as with or without complications. Documenting the patient presentation allows the coder to capture the necessary information to fully code the patient’s condition. The diabetes mellitus codes are combination codes that include the type, the body system affected and the complication(s) affecting the body system.
- E08 Diabetes mellitus due to underlying condition
- 35 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy
- 36 Diabetes mellitus due to underlying condition with diabetic cataract
- E09 Drug or chemical induced diabetes mellitus
- 3 Drug or chemical induced diabetes mellitus with ophthalmic complications
- 31 Type 2 diabetes mellitus with unspecified diabetic retinopathy
- 62 Type 2 diabetes mellitus with skin complications
- 65 Type 2 diabetes mellitus with hyperglycemia
- 69 Type 2 diabetes mellitus with other specified complication
Obesity
Overweight should be accompanied by documentation of body mass index (BMI). Though any clinician can capture and record a patient’s BMI, the provider is ultimately responsible for the completeness of diagnosis documentation.
- E65 Localized adiposity
- 01 Morbid (severe) obesity due to excess calories
- 1 Drug-induced obesity
- 2 Morbid (severe) obesity with alveolar hypoventilation
Osteoporosis
Medical records should detail any past history of healed osteoporosis fractures and provide information regarding the encounter type. Cause for the condition should also be clarified (age-related, drug-induced, or post-traumatic). If drug-induced, the specific drug should be listed.
- 051 Age-related osteoporosis with current pathological fracture, right femur
- 059 Age-related osteoporosis with current pathological fracture, unspecified femur
- 061 Age-related osteoporosis with current pathological fracture, right lower leg
- 07 Age-related osteoporosis with current pathological fracture, ankle and foot
- 08 Age-related osteoporosis with current pathological fracture, vertebra(e)
Thyroid Disorders
Documentation of thyroid problems should clearly designate the problem as:
- acute or chronic
- thyrotoxicosis, thyroiditis, goiter or hypothyroidism
- presence or absence of a diffuse goiter
ICD-10 codes used to document these disorders include:
- 2 Iodine-deficiency related (endemic) goiter, unspecified
- 3 Postinfectious hypothyroidism
- 0 Thyrotoxicosis with diffuse goiter
- 4 Thyrotoxicosis factitia
- 4 Drug-induced thyroiditis
- 81 Sick-euthyroid syndrome
- 9 Disorder of thyroid, unspecified
Cushing’s syndrome
Cushing’s syndrome can also be described as pituitary-dependent, drug-induced, alcohol-induced, Nelson’s syndrome, ectopic ACTH syndrome, or other.
- 0 Pituitary-dependent Cushing’s disease
- 1 Nelson’s syndrome
- 2 Drug-induced Cushing’s syndrome
- 3 Ectopic ACTH syndrome
- 4 Alcohol-induced pseudo-Cushing’s syndrome
Medical billing and coding companies provide the services of medical coders who are familiar with possible complexities associated with reporting endocrine conditions, diagnosis and treatment. By partnering with reliable firms, endocrinologists do not have to face any more issues due to delayed reimbursement, increased audit requests, changing codes, and unfamiliarity with the reimbursement policies of individual payers.
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