Diabetes Documentation
In Spite of ICD-10

Published in April 2014 Issue             

ASMBS Insurance Committee Member, Ann Couch, RN, CBN, CPC

Ann Couch, RN

Many of us are aware that ICD-10 has been delayed until 2015. This has been heralded as good news or bad news depending on where you stand on your readiness. With that said, the need for detailed documentation will benefit you now and the future. Not only for ICD-10 readiness, but also because the better documentation submitted to garner insurance carrier approval for bariatric surgery coverage, the better your overall volume can be.

Diabetes mellitus (DM) is defined by Wikipedia as “a group of metabolic diseases in which a person has high blood sugar.” Although “pre-diabetes” or hypoglycemia should be documented, if a patient carries a diagnosis of DM, then additional data is needed. The designation between Type 1 (Juvenile) and Type 2 (adult-onset), as well as whether or not the patient requires insulin to manage their diabetes and how long it has been needed, should be listed. Complications due to diabetes, such as retinopathy, kidney disease, neuropathy, etc. should also be documented.


This is a 45 year-old female who presents with a BMI of 37. She was diagnosed with Type 2 diabetes 10 years ago, and has required Lantus for the past 3 years. She has suffered from neuropathy in the left foot for the past 7 months due to her diabetes. She does not have any other comorbidities.

The benefits of making these small changes carry far. Although simple, for ICD-10, your coders and billing staff will jump for joy! This gives them the specificity that is going to be required. Your data reviewer will appreciate the extra specificity for the MBSAQIP database. For the insurance approval process, if you can show that this patient’s disease is progressing, there is a better standing with the carrier to show the benefit of an intervention for their weight. It can also help substantiate your billing, assuming you have the other parts of the Evaluation/Management complete.

Documentation will never go away. It not only benefits you and your staff, but it benefits the patient when they can get approval for bariatric surgery. And with specific details after metabolic/bariatric surgery, the data will reflect the benefits and the reversal or reduction of comorbidities, especially diabetes. It is with the hope that this data will allow for increased surgery coverage so that more patients can benefit.