Q&A: When to assign an ICD-10-CM code for history of diabetes

Q: We have a patient who received a pancreas transplant for the treatment of diabetes. The patient was later admitted to the hospital for treatment of an unrelated kidney stone. Would I still need to assign the ICD-10-CM code for diabetes as a chronic condition based on the patient’s medical history?

A: Once the patient received the pancreas transplant, the diabetes should no longer be present if the procedure outcome was successful. Only the pancreatic transplant status code would need to be assigned to show its presence. 

However, the patient can re-develop diabetes again if the transplant fails or rejects. Carefully review the documentation to note if the provider is still showing that the diabetes is present, ongoing, and/or being treated or if the patient only has a history of previous diabetes that is status-post transplant. 

If you are unable to determine if the diabetes is still present based on the documentation, a query can be submitted to the physician to provide clarification or confirmation as to the presence of the diabetes in this patient.

Editor’s note: Sarah Humbert, RHIA, AHIMA-certified ICD-10-CM/PCS trainer, coding and compliance manager at KIWI-TEK LLC, and Temeka Davis, RHIT, coding manager at KIWI-TEK LLC, answered this question during HCPro’s webinar Simplify Complex ICD-10-CM Coding for Diabetes.

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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