# Presentation: 155417

## ICD-9-CM Coordination and Maintenance Committee MeetingOctober 8th, 2004

- Edward J. Bastyr III, MD

- Promoting Clear Identification of Diabetic Peripheral Neuropathy

## Overview

- Clinical Manifestations and Diagnosis of Diabetic Peripheral Neuropathy
- Disease Epidemiology
- Inadequacy of Current Diagnostic Codes
- Proposed Modifications and Clarification
- Discussion

## Diabetic Peripheral Neuropathy

- Diabetic peripheral neuropathy (DPN) is a frequent complication of diabetes associated with significant morbidity and mortality1
- Risk factor for ulcers and amputations2
- Impairs quality of life1
- Significant resources are spent to treat patients with DPN
- Estimated total annual cost in US $4.6 - $13.7 billion3
- Only effective intervention is prevention by tight control of patient’s diabetes

- 1. Vinik AI, et.al. *Diabetologia* 2000;43: 957-973.
- 2. Standards of Medical Care in Diabetes. *Diabetes Care*. 2004;S1:15-35.
- 3. Gordois A, et.al. *Diabetes Care.* 2003;26: 1790-1795

## DPN is characterized by a stocking and glove distribution:
Bilateral symmetrical distribution of signs and symptoms
Affects lower limbs first
Progresses from distal (toes) to proximal (knee) over time.

- Bilateral symmetrical distribution of signs and symptoms
- Affects lower limbs first
- Progresses from distal (toes) to proximal (knee) over time.

**DPN affects the limbs symmetrically and progresses from distal to proximal over time**.

- Signs and symptoms progress from distal to proximal over time

- Diabetic Neuropathy (Boulton), 2001

- Clinical Manifestations

## Diagnosis

- Symptoms
- Numbness
- Tingling
- Painful Sensations
- Signs
- Lost  Reflexes, Decreased Sensation
- Joint Deformity, Skin changes
- Perception Measures
- Quantitative Sensory Testing
- Vibration Detection Threshold
- Cold Detection Threshold
- Heat Pain Threshold
- Objective Measures
- Electrophysiology (Nerve Conduction Studies)

## Epidemiology

- _Study Population            Data Collection         Prevalence (%)_
- Rochester Diabetic Neuropathy 	     1986			54% - Type I
- Study*							45% - Type II
- San Luis Valley Diabetes Study†	1984 – 1986		25.8%
- Pittsburgh Epidemiology of
- Diabetes Complications Study‡	1984 – 1988		34.0%

- DPN diagnosed on basis of: *Positive symptoms and electrophysiological testing1;
- 		         † Neurological exam2
- 		         ‡ Presence of two out of three: abnormal sensory or motor signs, symptoms,
- 		           decreased tendon reflexes3

- Reliable epidemiological information is complicated by differences in: Definition; Methodology  and Diagnostic Criteria

- Dyck PJ, et.al. *Neurology*. 1993;43: 817-24.
- Franklin GM, et.al. *Am J Epidemiol *1990;131:633-43.
- Maser RE, et.al. *Diabetes *1989;38(11):1456-61.

## Neuropathy Clinical Classification

**Stage 0**

**Stage 1**

**Stage 2**

**Stage 3**

** ****No Neuropathy**

- Abn NCV, NIS<2
- NSC<1

- Abn NCV, NIS>2,
- NSC <1

**  ****Asymptomatic Neuropathy**

-  **Disabling Neuropathy**

-  **Symptomatic Neuropathy**

- Abn NCV, NIS>2
- NIS(Q21)<4, NSC>1

- Disabling Symptoms
-     - Ulcers; deformity;
-        non-traumatic amputation

- Abnormal NCV and
- Nerve Exam

- Abn NCV, NIS>2
- NIS(Q21)>4, NSC>1

- NCV=nerve conduction velocity
- NIS=neuropathy impairment score
- NSC=neuropathy symptom and change score

- 50%
- 38%
- 8-12%
- 1-3%

- Dyck PJ, et.al. *Neurology*. 1993;43: 817-24.

## Inadequacy of Existing Codes

- Diabetic Polyneuropathy (357.2)
- Poorly defined epidemiology due to variations in diagnosis criteria
- DPN is a progressive disorder, current code does not allow for following disease progression
- Lack of unique codes results in the loss of valuable information
- Epidemiology
- Morbidity
- Utilization of services and costs

## Maintain 357.2 Polyneuropathy in Diabetes, but require that it coded to 5th digit
Continue to note under 357.2 code first underlying disease (250.6)
Create four unique codes to describe the different stages of Diabetic Peripheral Neuropathy
357.20 Unspecified Polyneuropathy in Diabetes
357.21 Asymptomatic Neuropathy in Diabetes
357.22 Symptomatic Neuropathy in Diabetes
357.23 Disabling Neuropathy in Diabetes

- Continue to note under 357.2 *code first underlying disease *(250.6)
- Create four unique codes to describe the different stages of Diabetic Peripheral Neuropathy
- 357.20 *Unspecified Polyneuropathy in Diabetes*
- 357.21 *Asymptomatic Neuropathy in Diabetes*
- 357.22 *Symptomatic Neuropathy in Diabetes*
- 357.23 *Disabling Neuropathy in Diabetes*

- Modification to Diabetic Polyneuropathy

## Conclusion

- DPN is a frequent, progressive complication of diabetes associated with significant morbidity and costs
- Current ICD-9-CM codes do not allow for categorization of the different stages of DPN resulting in the loss of valuable information on the epidemiology and costs of the disease
- Modification of current *Polyneuropathy in Diabetes* (357.2) code will better represent the clinical presentation of DPN
- 357.20 *Unspecified Polyneuropathy in Diabetes*
- 357.21 *Asymptomatic Neuropathy in Diabetes*
- 357.22 *Symptomatic Neuropathy in Diabetes*
- 357.23 *Disabling Neuropathy in Diabetes*

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