Nail Down the Appropriate Diabetes Dx Every Time

  Ambulatory Coding & Payment Report 2008: Volume 13, Number 5

Report only diabetic complications related to current episode of care

Patients with diabetes often have one or multiple complications that require the physician’s extra attention and consideration -- and which your coding should therefore reflect.

Use these four steps for definitive diabetes diagnosis coding to ensure that your ICD-9 codes justify the services you bill.

1. Select Fourth Digit First

You must determine the fourth digit for 250.xx (Diabetes mellitus) according to the type of diabetic complication the patient has, if any. Diabetes patients may have more than one complication. If this is the case, you should code only the complication relevant to services your physician renders that day.

2. Identify Type for Fifth Digit

The fifth digit provides the final two pieces of information on the patient’s diabetic condition: the diabetes type (I or II) and whether it is controlled.

To select the proper fifth digit, you must first know what the following ICD-9 descriptor terms mean:

Type I: The patient’s pancreatic beta cells no longer produce insulin. People with type I diabetes must take insulin. ICD-9 descriptors also refer to type I as “juvenile type” diabetes.

Type II: The patient’s beta cells do not produce sufficient insulin, or the beta cells have developed insulin resistance. People with type II may not have to take insulin.

Not stated as uncontrolled: The patient’s diabetes is managed sufficiently by diet and/or insulin.

Uncontrolled: A patient can have uncontrolled diabetes when the physician documents that blood sugar levels are not acceptably stable, when the patient is not in compliance with his diabetes management plan, or if the patient is taking medications for another illness that interfere with diabetes management.

First, check the physician’s documentation to see what type of diabetes the patient has and whether the condition is controlled. Then choose one of the following fifth digits:
• 0 -- Type II or unspecified type, not stated as uncontrolled
• 1 -- Type I (juvenile type), not stated as uncontrolled
• 2 -- Type II or unspecified type, uncontrolled
• 3 -- Type I (juvenile type), uncontrolled.

Don’t worry when your list of frequently used diagnoses turns up lots of 250.00s. “Ninety percent of diabetes in the United States is type II,” says Sheri Poe Bernard, CPC, CPC-H, CPC-P. “The default for documented diabetes would be 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled),” she said in her presentation “Understanding Diabetes” at a recent American Academy of Professional Coders’ conference.

3. Determine if Diabetes Is Primary

After you’ve chosen the patient’s correct 250.xx code, a new question can arise: Is diabetes the primary or secondary diagnosis?

In most cases, your surgeon will treat a problem not directly related to the diabetes, but you may still need to indicate the patient’s complete medical condition with a 250.xx code, Bernard says.

Because every diabetes case is different, there is no hard and fast rule regarding when the diabetes should be the patient’s primary or secondary diagnosis. The presenting problem’s nature should govern the diagnosis code.

Example: Diabetic patient with new foot ulcer. Code the foot ulcer as the primary diagnosis, and list the diabetes mellitus as the secondary diagnosis. Diabetes is secondary because it is a relevant condition that influences the patient’s treatment and care, as well as the ulcer’s cause. And the patient saw the doctor specifically for the foot ulcer, not for diabetes management.

4. Mind Your Manifestations

Five diabetes code fourth-digit descriptors require that you report a manifestation diagnosis code as well. Always report the manifestation code as a secondary diagnosis. And remember, not all diabetes fourth digits require a manifestation code. The code descriptor tells you if you need one.

Here’s a partial list of the diabetes codes that require a corresponding manifestation code, paired with some possible diabetic manifestations:
• 250.5x -- 366.41 (Cataract; cataract associated with other disorders; diabetic cataract)
• 250.6x -- 357.2 (Inflammatory and toxic neuropathy; polyneuropathy in diabetes)
• 250.7x -- 443.81 (Other peripheral vascular disease; other specified peripheral vascular diseases; peripheral angiopathy in diseases classified elsewhere).

Keep in mind: The ICD-9 manual does not list all possible manifestation codes that you might need to choose from when you report one of the 250.xx codes above.

You can report them all: If a patient has more than one diabetic complication, you can code the multiple complications and their manifestations on a single claim, making sure to link the manifestations to the correct diabetes codes.-

For example, if your surgeon treats a patient for diabetes with renal manifestations and the patient also has ophthalmic manifestations, report both sets of codes. Usually the prescription management or plan of care needs to consider these other manifestations.

Sequence matters: Remember to report first the particular manifestation your physician treats that day. Or if the physician is dealing with multiple complications, code according to the order in which the physician renders treatment. Finally, if the documentation does not indicate the treatment order, you should report the most prominent or advanced complication and corresponding manifestation first.