The 318 ICD-10-CM codes for diabetes mellitus

In a previous post, we pointed out that despite the fact that there are very few known subtypes of diabetes mellitus, ICD-10-CM has approximately 290 codes for diabetes mellitus, not counting gestational diabetes mellitus.

In the 2009 release of ICD-10-CM, we count a total of 318 codes for diabetes mellitus, including gestational diabetes mellitus. The reason for the large number of codes is that ICD-10-CM combines multiple disease classes into a single code.

For example, the ICD-10-CM code E11.621 Type 2 diabetes mellitus with foot ulcer, contains two disease classes: diabetes mellitus and foot ulcer. For sure, this code implicitly means that the former caused the latter (note that this causal relationship is inaccessible to the computer), but that augments our point. Nothing is its own cause and thus these two diseases are distinct.

We provide here on Google docs the 318 codes and their text strings, in a spreadsheet format that anyone can at least copy-and-paste into their own spreadsheet or database table. An easy way to demonstrate the needless complexity caused by combination codes.

The blogosphere recognizes the pitfalls of ICD-10-CM

The blogosphere is coming to the realization that ICD-10-CM has substantial problems.

Dr. Wes, in a post on October 25th entitled "Ten Times the Fun," laments:

Imagine, 290 codes just for diabetes! Yeeeee haaaaa! Diabetes with foot ulcers on the right foot gets one code, diabetes with foot ulcers on the left foot gets another code, diabetes with foot ulcers on both feet, but not involving the shins gets another code... I mean, a new code for every nuance of disease! You get the drift! Isn't this SPECIAL? Just think of the COST SAVINGS those clever bureaucrats have found!

Meanwhile, Richard Elmore in a post on his Healthcare Technology News blog on October 29th, entitled "More painful than an insect bite? ICD-10 cost-benefit for healthcare providers," lists all 87 ICD-10-CM codes for diagnoses of insect bites. These 87 codes replace 18 ICD-9-CM codes, a 4.8 fold increase.

Mr. HISTalk linked to Dr Wes' post in his October 27th entry. Mr. HISTalk also linked to Richard Elmore's post in his October 31st entry.

Readers of Mr. HISTalk are similarly not impressed with ICD-10-CM. Comments from Mr. HISTalk readers (not including the comments of yours truly) include the following:

The lists of codes are in general a slavish enumeration of nearly every possible combination of pathology, anatomic location, laterality, and ordinality of visit.

They [NCHS] are distributing it [ICD-10-CM] in a text file to:

1. Reduce the most “arduous” task - writing an upload and deduplication routine
2. Keep a non-Government entity (3M?) on the payroll to “manage” the process for them

Disease classification as patronage?

The blogosphere isn't fooled. ICD-10-CM is a poorly designed and executed boondoggle.

Combination code explosion: An illustration

The Blue Cross Blue Shield Association highlights the complexity of ICD-10-CM in a presentation on its web site.

On slide 9 of the presentation is a nice illustration of how ICD-10-CM takes a single code from ICD-10 and explodes it out into 144 codes. ICD-10-CM is based on ICD-10 from the World Health Organization. Individual member countries may modify ICD-10 within certain constraints. Australia (ICD-10-AM) and Canada (ICD-10-CA) both have made modifications.

Well, when the National Center for Health Statistics modified ICD-10 to create the United States' clinical modification or ICD-10-CM, it frequently took one or a small number of ICD-10 codes and "expanded" them out to a much larger number of combination codes.

Going back to the illustration of combination-code explosion from the BCBSA, ICD-10 has code S42.0 for fracture of the clavicle (the clavicle is also commonly referred to as the collar bone).

Canada chose to expand this code out to eight codes in ICD-10-CA:

1. S42.01 - fracture of sternal end of clavicle
   
2. S42.01 - fracture of shaft of clavicle
   
3. S42.02 - fracture of acromial end of clavicle
   
4. S42.09 - fracture of unspecified part of clavicle
   
5. S47 - multiple fractures of clavicle
   
6. M84.11 - nonunion, shoulder region
   
7. M84.21 - delayed union, shoulder region
   
8. M84.22 - malunion, shoulder region

Below, we list the 144, seven-character ICD-10-CM codes for fracture of the clavicle. The 144 codes add laterality, whether the fracture is displaced and if so in what direction, and information about which encounter and whether there is "routine healing", malunion, and so on. Note that all the four-, five-, and six-character codes beginning with S42.0 (it is typical in ICD not to count the decimal point as a character) are also part of ICD-10-CM. There are 1 four-character, 4 five-character, and 24 six-character codes, for a grand total of 173 codes, although only the 144 seven-character codes will be valid for reimbursement (in all likelihood).

From one code to 173 codes as we go from ICD-10 to ICD-10-CM. Combinatorial explosion.

ICD-10: ~12,000-13,000 codes
ICD-10-AM: ~16,000 codes
ICD-10-CA: ~30,000 codes
ICD-10-CM: >68,000 codes

The 144, seven-character ICD-10-CM codes for fracture of the clavicle (with thanks to the BCBSA):

1. S42.001A Unspecified part of right clavicle, initial encounter for closed fracture
2. S42.001D Unspecified part of right clavicle, subsequent encounter for fracture with routine healing
3. S42.001G Unspecified part of right clavicle, subsequent encounter for fracture with delayed healing
4. S42.001K Unspecified part of right clavicle, subsequent encounter for fracture with nonunion
5. S42.001P Unspecified part of right clavicle, subsequent encounter for fracture with malunion
6. S42.001S Unspecified part of right clavicle, sequalae
7. S42.002A Unspecified part of left clavicle, initial encounter for closed fracture
8. S42.002D Unspecified part of left clavicle, subsequent encounter for fracture with routine healing
9. S42.002G Unspecified part of left clavicle, subsequent encounter for fracture with delayed healing
10. S42.002K Unspecified part of left clavicle, subsequent encounter for fracture with nonunion
11. S42.002P Unspecified part of left clavicle, subsequent encounter for fracture with malunion
12. S42.002S Unspecified part of left clavicle, sequalae
13. S42.009A Unspecified part of unspecified clavicle, initial encounter for closed fracture
14. S42.009D Unspecified part of unspecified clavicle, subsequent encounter for fracture with routine healing
15. S42.009G Unspecified part of unspecified clavicle, subsequent encounter for fracture with delayed healing
16. S42.009K Unspecified part of unspecified clavicle, subsequent encounter for fracture with nonunion
17. S42.009P Unspecified part of unspecified clavicle, subsequent encounter for fracture with malunion
18. S42.009S Unspecified part of unspecified clavicle, sequalae
19. S42.011A Anterior displaced fracture of sternal end of right clavicle, initial encounter for closed fracture
20. S42.011D Anterior displaced fracture of sternal end of right clavicle, subsequent encounter for fracture with routine healing
21. S42.011G Anterior displaced fracture of sternal end of right clavicle, subsequent encounter for fracture with delayed healing
22. S42.011K Anterior displaced fracture of sternal end of right clavicle, subsequent encounter for fracture with nonunion
23. S42.011P Anterior displaced fracture of sternal end of right clavicle, subsequent encounter for fracture with malunion
24. S42.011S Anterior displaced fracture of sternal end of right clavicle, sequalae
25. S42.012A Anterior displaced fracture of sternal end of left clavicle, initial encounter for closed fracture
26. S42.012D Anterior displaced fracture of sternal end of left clavicle, subsequent encounter for fracture with routine healing
27. S42.012G Anterior displaced fracture of sternal end of left clavicle, subsequent encounter for fracture with delayed healing
28. S42.012K Anterior displaced fracture of sternal end of left clavicle, subsequent encounter for fracture with nonunion
29. S42.012P Anterior displaced fracture of sternal end of left clavicle, subsequent encounter for fracture with malunion
30. S42.012S Anterior displaced fracture of sternal end of left clavicle, sequalae
31. S42.013A Anterior displaced fracture of sternal end of unspecified clavicle, initial encounter for closed fracture
32. S42.013D Anterior displaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with routine healing
33. S42.013G Anterior displaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with delayed healing
34. S42.013K Anterior displaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with nonunion
35. S42.013P Anterior displaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with malunion
36. S42.013S Anterior displaced fracture of sternal end of unspecified clavicle, sequalae
37. S42.014A Posterior displaced fracture of sternal end of right clavicle, initial encounter for closed fracture
38. S42.014D Posterior displaced fracture of sternal end of right clavicle, subsequent encounter for fracture with routine healing
39. S42.014G Posterior displaced fracture of sternal end of right clavicle, subsequent encounter for fracture with delayed healing
40. S42.014K Posterior displaced fracture of sternal end of right clavicle, subsequent encounter for fracture with nonunion
41. S42.014P Posterior displaced fracture of sternal end of right clavicle, subsequent encounter for fracture with malunion
42. S42.014S Posterior displaced fracture of sternal end of right clavicle, sequalae
43. S42.015A Posterior displaced fracture of sternal end of left clavicle, initial encounter for closed fracture
44. S42.015D Posterior displaced fracture of sternal end of left clavicle, subsequent encounter for fracture with routine healing
45. S42.015G Posterior displaced fracture of sternal end of left clavicle, subsequent encounter for fracture with delayed healing
46. S42.015K Posterior displaced fracture of sternal end of left clavicle, subsequent encounter for fracture with nonunion
47. S42.015P Posterior displaced fracture of sternal end of left clavicle, subsequent encounter for fracture with malunion
48. S42.015S Posterior displaced fracture of sternal end of left clavicle, sequalae
49. S42.016A Posterior displaced fracture of sternal end of unspecified clavicle, initial encounter for closed fracture
50. S42.016D Posterior displaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with routine healing
51. S42.016G Posterior displaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with delayed healing
52. S42.016K Posterior displaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with nonunion
53. S42.016P Posterior displaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with malunion
54. S42.016S Posterior displaced fracture of sternal end of unspecified clavicle, sequalae
55. S42.017A Nondisplaced fracture of sternal end of right clavicle, initial encounter for closed fracture
56. S42.017D Nondisplaced fracture of sternal end of right clavicle, subsequent encounter for fracture with routine healing
57. S42.017G Nondisplaced fracture of sternal end of right clavicle, subsequent encounter for fracture with delayed healing
58. S42.017K Nondisplaced fracture of sternal end of right clavicle, subsequent encounter for fracture with nonunion
59. S42.017P Nondisplaced fracture of sternal end of right clavicle, subsequent encounter for fracture with malunion
60. S42.017S Nondisplaced fracture of sternal end of right clavicle, sequalae
61. S42.018A Nondisplaced fracture of sternal end of left clavicle, initial encounter for closed fracture
62. S42.018D Nondisplaced fracture of sternal end of left clavicle, subsequent encounter for fracture with routine healing
63. S42.018G Nondisplaced fracture of sternal end of left clavicle, subsequent encounter for fracture with delayed healing
64. S42.018K Nondisplaced fracture of sternal end of left clavicle, subsequent encounter for fracture with nonunion
65. S42.018P Nondisplaced fracture of sternal end of left clavicle, subsequent encounter for fracture with malunion
66. S42.018S Nondisplaced fracture of sternal end of left clavicle, sequalae
67. S42.019A Nondisplaced fracture of sternal end of unspecified clavicle, initial encounter for closed fracture
68. S42.019D Nondisplaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with routine healing
69. S42.019G Nondisplaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with delayed healing
70. S42.019K Nondisplaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with nonunion
71. S42.019P Nondisplaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with malunion
72. S42.019S Nondisplaced fracture of sternal end of unspecified clavicle, sequalae
73. S42.021A Displaced fracture of shaft of right clavicle, initial encounter for closed fracture
74. S42.021D Displaced fracture of shaft of right clavicle, subsequent encounter for fracture with routine healing
75. S42.021G Displaced fracture of shaft of right clavicle, subsequent encounter for fracture with delayed healing
76. S42.021K Displaced fracture of shaft of right clavicle, subsequent encounter for fracture with nonunion
77. S42.021P Displaced fracture of shaft of right clavicle, subsequent encounter for fracture with malunion
78. S42.021S Displaced fracture of shaft of right clavicle, sequalae
79. S42.022A Displaced fracture of shaft of left clavicle, initial encounter for closed fracture
80. S42.022D Displaced fracture of shaft of left clavicle, subsequent encounter for fracture with routine healing
81. S42.022G Displaced fracture of shaft of left clavicle, subsequent encounter for fracture with delayed healing
82. S42.022K Displaced fracture of shaft of left clavicle, subsequent encounter for fracture with nonunion
83. S42.022P Displaced fracture of shaft of left clavicle, subsequent encounter for fracture with malunion
84. S42.022S Displaced fracture of shaft of left clavicle, sequalae
85. S42.023A Displaced fracture of shaft of unspecified clavicle, initial encounter for closed fracture
86. S42.023D Displaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with routine healing
87. S42.023G Displaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with delayed healing
88. S42.023K Displaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with nonunion
89. S42.023P Displaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with malunion
90. S42.023S Displaced fracture of shaft of unspecified clavicle, sequalae
91. S42.024A Nondisplaced fracture of shaft of right clavicle, initial encounter for closed fracture
92. S42.024D Nondisplaced fracture of shaft of right clavicle, subsequent encounter for fracture with routine healing
93. S42.024G Nondisplaced fracture of shaft of right clavicle, subsequent encounter for fracture with delayed healing
94. S42.024K Nondisplaced fracture of shaft of right clavicle, subsequent encounter for fracture with nonunion
95. S42.024P Nondisplaced fracture of shaft of right clavicle, subsequent encounter for fracture with malunion
96. S42.024S Nondisplaced fracture of shaft of right clavicle, sequalae
97. S42.025A Nondisplaced fracture of shaft of left clavicle, initial encounter for closed fracture
98. S42.025D Nondisplaced fracture of shaft of left clavicle, subsequent encounter for fracture with routine healing
99. S42.025G Nondisplaced fracture of shaft of left clavicle, subsequent encounter for fracture with delayed healing
100. S42.025K Nondisplaced fracture of shaft of left clavicle, subsequent encounter for fracture with nonunion
101. S42.025P Nondisplaced fracture of shaft of left clavicle, subsequent encounter for fracture with malunion
102. S42.025S Nondisplaced fracture of shaft of left clavicle, sequalae
103. S42.026A Nondisplaced fracture of shaft of unspecified clavicle, initial encounter for closed fracture
104. S42.026D Nondisplaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with routine healing
105. S42.026G Nondisplaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with delayed healing
106. S42.026K Nondisplaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with nonunion
107. S42.026P Nondisplaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with malunion
108. S42.026S Nondisplaced fracture of shaft of unspecified clavicle, sequalae
109. S42.031A Displaced fracture of lateral end of right clavicle, initial encounter for closed fracture
110. S42.031D Displaced fracture of lateral end of right clavicle, subsequent encounter for fracture with routine healing
111. S42.031G Displaced fracture of lateral end of right clavicle, subsequent encounter for fracture with delayed healing
112. S42.031K Displaced fracture of lateral end of right clavicle, subsequent encounter for fracture with nonunion
113. S42.031P Displaced fracture of lateral end of right clavicle, subsequent encounter for fracture with malunion
114. S42.031S Displaced fracture of lateral end of right clavicle, sequalae
115. S42.032A Displaced fracture of lateral end of left clavicle, initial encounter for closed fracture
116. S42.032D Displaced fracture of lateral end of left clavicle, subsequent encounter for fracture with routine healing
117. S42.032G Displaced fracture of lateral end of left clavicle, subsequent encounter for fracture with delayed healing
118. S42.032K Displaced fracture of lateral end of left clavicle, subsequent encounter for fracture with nonunion
119. S42.032P Displaced fracture of lateral end of left clavicle, subsequent encounter for fracture with malunion
120. S42.032S Displaced fracture of lateral end of left clavicle, sequalae
121. S42.033A Displaced fracture of lateral end of unspecified clavicle, initial encounter for closed fracture
122. S42.033D Displaced fracture of lateral end of unspecified clavicle, subsequent encounter for fracture with routine healing
123. S42.033G Displaced fracture of lateral end of unspecified clavicle, subsequent encounter for fracture with delayed healing
124. S42.033K Displaced fracture of lateral end of unspecified clavicle, subsequent encounter for fracture with nonunion
125. S42.033P Displaced fracture of lateral end of unspecified clavicle, subsequent encounter for fracture with malunion
126. S42.033S Displaced fracture of lateral end of unspecified clavicle, sequalae
127. S42.034A Nondisplaced fracture of lateral end of right clavicle, initial encounter for closed fracture
128. S42.034D Nondisplaced fracture of lateral end of right clavicle, subsequent encounter for fracture with routine healing
129. S42.034G Nondisplaced fracture of lateral end of right clavicle, subsequent encounter for fracture with delayed healing
130. S42.034K Nondisplaced fracture of lateral end of right clavicle, subsequent encounter for fracture with nonunion
131. S42.034P Nondisplaced fracture of lateral end of right clavicle, subsequent encounter for fracture with malunion
132. S42.034S Nondisplaced fracture of lateral end of right clavicle, sequalae
133. S42.035A Nondisplaced fracture of lateral end of left clavicle, initial encounter for closed fracture
134. S42.035D Nondisplaced fracture of lateral end of left clavicle, subsequent encounter for fracture with routine healing
135. S42.035G Nondisplaced fracture of lateral end of left clavicle, subsequent encounter for fracture with delayed healing
136. S42.035K Nondisplaced fracture of lateral end of left clavicle, subsequent encounter for fracture with nonunion
137. S42.035P Nondisplaced fracture of lateral end of left clavicle, subsequent encounter for fracture with malunion
138. S42.035S Nondisplaced fracture of lateral end of left clavicle, sequalae
139. S42.036A Nondisplaced fracture of lateral end of unspecified clavicle, initial encounter for closed fracture
140. S42.036D Nondisplaced fracture of lateral end of unspecified clavicle, subsequent encounter for fracture with routine healing
141. S42.036G Nondisplaced fracture of lateral end of unspecified clavicle, subsequent encounter for fracture with delayed healing
142. S42.036K Nondisplaced fracture of lateral end of unspecified clavicle, subsequent encounter for fracture with nonunion
143. S42.036P Nondisplaced fracture of lateral end of unspecified clavicle, subsequent encounter for fracture with malunion
144. S42.036S Nondisplaced fracture of lateral end of unspecified clavicle, sequalae