About 1 in 3 American adults has prediabetes, so the condition is almost certain to affect you, sooner or later, and directly or indirectly. Like any medical condition, prediabetes brings up the likelihood of healthcare, with communication and payment being critical elements of a smooth system.
The prediabetes ICD-10 code can clarify medical care for patients, providers, and insurers, and probably for you. Following are some questions you might have about it, and their simple answers.
What is prediabetes?
Prediabetes is a condition of high blood sugar (blood glucose), but at a level that is not as high as in diabetes. Having prediabetes is like being at a fork in the road. On one hand, it puts you at higher risk for developing type 2 diabetes, with most prediabetic patients developing diabetes within 10 years. On the other hand, being diagnosed with prediabetes gives you the chance to make changes to lower your risk for type 2 diabetes. These include:
Losing extra weight.
Increasing physical activity.
Avoiding tobacco use.
What are the International Code of Diagnostics and ICD-10?
The International Code of Diagnostics (ICD) is the international system for streamlining medical care. The World Health Organization (WHO) has been publishing versions of the ICD since 1948. It is now on the tenth version, ICD-10, which has been adopted for use by over 100 countries, including the U.S.
Compared to ICD-9, ICD-10 has more codes and specificity. The former has 14,000 codes, while ICD-10 has over 70,000. In ICD-9, prediabetes falls under 790.29: “Other abnormal blood glucose.” Sharing this diagnosis include hypoglycemia, hyperglycemia due to steroids, prediabetes, and over 20 other symptoms.
What are the functions of ICD-10 for prediabetes?
While ICD-10-M is used for mortality statistics, ICD-10-CM [clinical modification] is used for morbidities, such as prediabetes. It has been used in the U.S. since 2015, and was published by the Centers for Medicare and Medicaid (CMS).
The ICD-10-CM classifications help patients, providers, and insurers to get on the same page regarding patient status. The standardized system, including a prediabetes ICD-10 code with specific criteria, reduce communication problems and potential conflict over the diagnosis, course of treatment, and payment requirements. For each group:
Patients: know your diagnosis of prediabetes and point to the ICD-10 code if you need to tell it to various doctors or when talking to your healthcare insurance company.
Providers: communicate with patients, and justify further diagnostic tests and prediabetes treatment plans.
Insurers: approve reimbursement for services related to prediabetes.
Another use of ICD-10-CM is for keeping statistics. The National Center for Health Statistics (NCHS) within the National Institutes of Health (NIH) uses ICD-10 data to monitor population health. Having a standard prediabetes ICD-10 code allows the NCHS to know how many people are diagnosed with prediabetes in a given year, and whether that number is increasing. These data are valuable when making decisions about funding, such as the decision to reimburse Diabetes Prevention Programs upon seeing the explosion in prediabetes in the population.
Who needs to know about prediabetes ICD-10?
Many people, probably even you, should know about ICD-10 for prediabetes. That is because you may be one of those people. If not, you may be someone with a prediabetic family member or friend. Or, you may be someone at high risk for prediabetes, so ICD-10 could be relevant in the near future.
If you are not looking at prediabetes from a patient perspective, ICD-10 could be even more critical. You could be a provider who cares for prediabetic patients – do not forget that on average, nearly half of your patients have prediabetes if you treat a standard population of adults over 65 years. Or, you could represent an insurer who needs to know the information from the other end.
What is the ICD-10 code for prediabetes?
The ICD-10 code for prediabetes is R73.03.
The “R” corresponds to section XVIII, entitled, “Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified.”
“R70-79” correspond to, “abnormal findings on examination of blood, without diagnosis.”
The “73” indicates, “Elevated blood glucose level.”
The “.03” indicates, “Prediabetes.”
When would I get an ICD-10 code for prediabetes?
Your doctor can put a prediabetes ICD-10 code on your record if you have prediabetes. The American Diabetes Association (ADA) uses results of blood tests as the diagnostic criteria. You have any of the following.
Fasting blood glucose (FBG) 100-125 mg/dl.
A1C (glycated hemoglobin) 5.7 to 6.4%.
Oral glucose tolerance test 140-199 mg/dl.
The guidelines for diagnosing prediabetes including repeating the test to confirm the results.
Which ICD-10 codes are related to the code for prediabetes?
Other ICD-10 codes are used to describe abnormal blood glucose levels that are from conditions besides prediabetes. For example, R73.9 designates “hyperglycemia, unspecified?”
The R73.03 ICD-10 code for prediabetes specifically excludes:
Types 1 and 2 diabetes
These each have different ICD-10 codes assigned to them.
Is ICD-10 current?
Yes, ICD-10 is the current set of codes internationally. The World Health Organization published a version of ICD-11 in June of 2018, but this version will not be finalized and implemented for a while. The new set of codes will be modified in 2019, and implemented by member states in 2022.
The new guidelines are designed to assist doctors in being more specific about diseases and related conditions. For example, a patient could have a primary diagnosis of type 2 diabetes, with a “manifestation” of diabetic retinopathy. There is also room to explain, via supplemental extension codes, details such as diagnosis or history.
Another change in ICD-11 is the recognition of traditional medicine in addition to just western medicine. The chapter outlines various disorders and how they develop according to different philosophies, such as Traditional Chinese Medicine (TCM), which has been used for centuries to explain and manage high blood sugar.
What benefits can you get from having a prediabetes ICD-10 diagnosis?
Whether you are a patient, healthcare provider, or doctor, documentation can only help. By using the standardized prediabetes ICD-10 code, you can be sure that each party is on the same page regarding patient status. This facilitates justification and reimbursement for further tests, prescriptions, and other treatments that may be required.
Proclaiming that you or your patient has prediabetes can be an important step in managing it to delay or prevent the onset of type 2 diabetes. With the official classification of prediabetes on the record, patients could have more opportunities open to them.
One particularly important program is the Diabetes Prevention Program (DPP). This program is CDC-recognized as an effective way to lower your risk for type 2 diabetes. It has a year-long curriculum that focuses on weight loss, healthy eating, and physical activity.
Referring patients to DPP is an Improvement Activity within Medicare’s Merit-Based Incentive System (MIPS) program. Many patients in Medicare and with other coverage plan are eligible to enroll in a DPP without out-of-pocket cost.
You may even be able to join a digital Diabetes Prevention Program such as Lark, which enables you to experience the curriculum without going to in-person meetings. Lark DPP is a health coach with 24/7 availability on your smartphone.
The ICD-10 prediabetes classification is a good way to standardize patient care and billing. In a healthcare system that often seems scattered and overwhelming, that can only be a good thing for patients, providers, and insurers!