ED Coding and Reimbursement Alert

ICD-9 revamps the fifth digit for diabetes mellitus

If you haven't gotten up to speed on the new rules for reporting ICD-9 codes for diabetes mellitus (DM) and chronic kidney disease (CKD), now's the time.

Why? Both 2005 and 2006 have brought more specific instructions for reporting DM diagnoses, especially for codes from the 250 category.
 
Also, EDs that treat CKD patients need to know the ICD-9 codes from the 585.1-585.5 series, which describe the disease in five clear stages.

But you don't have to worry about drowning in all the DM and CKD changes -quot; we-ve boiled them down to the essentials with the following advice.

250.xx Drives DM Coding

For starters, you-ll need to sequence the appropriate code(s) from the 250 series before any codes describing associated conditions, says Anita Hart, RHIA, CCS, CCS-P, ICD-9-CM and ICD-10 product manager for Ingenix Inc.

Good news: You won't have to pick just one code from the 250 series to describe all the patient's associated conditions if she has multiple ones--so you-re not under the burden to decide which one is most important.

Bad news: That means you have to describe all the conditions, which can mean more searching through a chart or physician's notes.

Count on 5th Digit for Diabetes Codes

Remember that the new guidelines require a fifth digit on all category 250 codes to identify the type of DM and whether the condition is controlled or uncontrolled, says Hart, who presented on the new ICD-9 codes at the Fifth Annual Ingenix Essentials conference.

In order to assign a fifth digit of -2- or -3,- you must have physician documentation that the DM is uncon-trolled, Hart says.

Ax these: Certain descriptions you may have relied on in the past are no longer in the DM diagnosis codes, such as -IDDM type,- -NIDDM type,- -adult-onset type,- -non-insulin-dependent- and -insulin-dependent.-

Check Insulin for Additional Codes

The 2006 DM guidelines also ask you to report routine insulin use and problems with insulin pumps, including underdosage and overdosage.

For type II patients who routinely use insulin, you-ll report V58.67 (Long-term [current] use of insulin).

But you should avoid this code in cases in which the physician just administered insulin temporarily to bring a type II patient's blood sugar under control during an encounter, Hart says.

When the patient's insulin pump malfunctions, you-ll report the following code sequences:

Overdose
 
- 996.57--Mechanical complication due to insulin pump (primary diagnosis)

- 962.3--Poisoning by insulins and antidiabetic agents (secondary diagnosis)

- 250.xx--Diabetes mellitus code based on documentation (secondary diagnosis), poisoning with manifestation of overdose.

Underdose

- 996.57--Mechanical complication due to insulin pump (primary diagnosis)

- 250.xx--Diabetes mellitus code based on documentation (secondary diagnosis), complication with manifestation of disease.

Determine Stage for Accurate CKD Coding

When your ED treats a patient who has had chronic kidney disease (CKD) for longer than three months, you-ll need to use one of the codes from the 585.1-585.5 series, which describe the disease in five stages.
 
In addition to the five -stage- codes for CKD, CMS also introduced a new end-stage renal disease (ESRD) code and an unspecified CKD code. This is welcome news to coders who want the most specific CKD diagnoses possible for their patients.

-The expanded CKD classification allows the coder and the physician to paint a clearer picture of the patient's condition and, in turn, may justify the appropriate course of treatment,- says Tara Conklin, CPC, an independent coding consultant in Wesley Chapel, Fla.

Quick tip: The 585 category's fourth digits simply specify in chronological order the five CKD stages from least severity (stage I) to greatest (stage V).

So, if the medical notes say the patient has stage III CKD, you would list code 585.3.

Learn the New Code Set

- 585.1--Chronic kidney disease, stage I. Use this code for patients who have kidney damage with normal or increased glomerular filtration rate (GFR), greater than or equal to 90 ml/min.

- 585.2--... stage II (mild). This code represents kidney damage with mild decrease in GFR, 60-89 ml/min.

- 585.3--... stage III (moderate). List this code when the patient has a moderate decrease in GFR, 30-59 ml/min.

- 585.4--... stage IV (severe). In this case, there has been a severe decrease in GFR, 15-29 ml/min.

- 585.5--... stage V. You-ll need this code for two conditions: kidney damage with GFR of less than 15 ml/min/1.73m, or kidney failure with GFR less than 15 ml/min (assuming the patient isn't on dialysis).
 
- 585.6--End-stage renal disease. Report this code if the patient has stage V kidney disease and is on dialysis.

- 585.9--Chronic kidney disease, unspecified. Use this code for chronic renal insufficiency and chronic renal failure not otherwise specified (NOS).