ED Coding and Reimbursement Alert

 Pathology, complications, and control unlock diagnoses

As research continues to reveal new information about the nature and treatment of diabetes mellitus (DM), the information you need to code it correctly changes, too. Use these expert-supplied tips to keep abreast of the clinical details and ensure your 250.xx code assignments are on target.

Take These Type Hints

The type of diabetes the patient has will often determine the fifth digit of the diagnosis code 250.xx. For patients with type I diabetes, you'll report a fifth digit of  1 (Type I [juvenile type], not stated as uncontrolled) or 3 (Type I [juvenile type], uncontrolled).
 
For type II patients, the fifth digit with be 0 (Type II or unspecified type, not stated as uncontrolled) or 2 (Type II or unspecified type, uncontrolled). Once you figure out the patient's type, you'll need to know whether the condition is controlled or uncontrolled to choose the appropriate fifth digit.
 
These tips should help you choose the correct type - and therefore the correct code:
 
Tip: Some things do stay the same. Once a patient has diabetes, he doesn't usually change types, says Garry Huff, MD, CCS, associate director of DRG Review Inc., who presented on diabetes coding at a recent American Health Information Management Association (AHIMA) meeting. "Once a type I, always a type I, once a type II, always a type II" is a helpful rule of thumb, he says. There are exceptions, but they aren't common - so if you see that a patient has a history of type I diabetes, you're safe reporting a fifth digit of "1" or "3," depending on whether the patient's condition is under control.
 
Tip: DKA is often a type I giveaway. One major difference between type I and type II diabetes is that type I patients may be completely stable and then go into diabetic ketoacidosis (DKA) with little to no warning. Type II patients, on the other hand, are more variable on a regular basis. "DKA is more of a type I complication," Huff says. "Type I patients have no insulin, and type IIs do, so type I patients are more prone to DKA."
 
Mark the spot: If you see "positive serum acetone" in the documentation, it usually indicates DKA, Huff says - and therefore, a type I patient. But if the physician writes that without specifically stating DKA, you should ask him before assuming the patient is type I.
 
Tip: Insulin dependence no longer indicates type.

Find a new way: If you've been using insulin dependence to determine that fifth digit, you've been out of luck this year. Since the code descriptors for diabetes changed for 2005, a patient's status as insulin-dependent or non-insulin-dependent is not a determining factor in establishing whether the patient is type I or II, says Deborah Grider, CMA, CPC, CPC-H, CCS-P, CCP, president of Medical Professionals Inc. in Indianapolis - so don't rely on it. The two main types of diabetes mellitus are distinguished by the function of beta cells in the pancreas, she says.

Know Your Type

With the 2005 ICD-9 changes distinguishing between type I and type II, distinguishing between these patients is more important than ever. Type I is due to autoimmune destruction of the pancreatic beta cells, which then causes the patient to stop insulin production entirely. These patients produce no insulin and need regular insulin injections
 
Type II, on the other hand, is caused by the body's inability to respond to insulin. This can usually be treated with oral medications, dietary modification, exercise and weight loss.
 
Tip: Figure out where pregnancy fits for 648.0x (Diabetes mellitus). You won't report true gestational diabetes with the 250 code series, so you need to distinguish between patients who have diabetes and then conceive (not gestational) and patients who have diabetes because of the pregnancy (gestational).
 
True gestationally diabetic patients will generally stop being diabetic once the baby is born.
 
For these patients, instead of using the 250 series, you should report gestational diabetes with a code from 648.8x (the fifth digit based on the patient's condition), says Grider, who presented on ICD-9 coding at the American Academy of Professional Coders 13th Annual Conference. Before you report gestational diabetes for a pregnant patient, take a second look at the documentation to discern whether she had the condition before she became pregnant, Huff says.

Control Your Conclusions

Once you've narrowed down the patient's type, your next step in determining the correct fifth digit is to figure out whether the DM is controlled. Follow these hints to ease your choice:
 
Do: Consider the terms "uncontrolled" and "poorly controlled" synonymous. You usually don't need to query the physician when one of them appears in the documentation, Huff says.
 
Don't: You shouldn't assume that "poorly controlled" and "new onset" mean the same thing as "out of control" - they're not synonymous.
 
Remember: "Control" won't translate into the same clinical parameters for every patient. It's individualized, based on the nature of the patient's condition and the best reasonable scenario the physician should expect for that patient.
 
However, certain parameters often indicate that a patient's diabetes is uncontrolled

  Diabetic symptoms, such as weight loss, thirst and polyuria often leading to dehydration

  High levels of glucose in the urine 

  Very high blood glucose (often >250)

  Diabetic ketoacidosis (DKA)or nonketotic hyperosmolar state (NKHS)

  Elevated HbA1c levels indicating past control over the last 2-3 months

Simplify Complication Reporting

There are only two situations in which you can report a code for diabetic complications. Either the physician specifically links the two conditions (for example, diabetes and a foot ulcer) or the ICD-9-CM manual states an assumed causal relationship with diabetes mellitus, Huff says.
 
For the complications with assumed causal relationships in ICD-9 - gangrene, osteomyelitis, peripheral vascular disease, and neuropathic arthritis - you should report the following codes:

  gangrene - 250.7x (Diabetes with peripheral circulatory disorders), 785.4 (Gangrene)

  osteomyelitis - 250.8x (Diabetes with other specified manifestations), 731.8 (Other bone involvement in diseases classified elsewhere)

  peripheral vascular disease - 250.7x (Diabetes with peripheral circulatory disorders), 443.81 (Peripheral angiopathy in diseases classified elsewhere)

  neuropathic arthritis - 250.6x (Diabetes with neurological manifestations), 713.5 (Arthropathy associated with neurological disorders).

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Correction: Diabetes

In the August 2005 issue of ED Coding Alert, the article "Clear 5th-Digit DM Obstacles With These Rules of Thumb" contained a mistake. Under the heading "Control Your Conclusions," Dr. Garry Huff was cited as saying that "uncontrolled" and "poorly controlled" are synonymous when describing diabetes.
 
In fact, Dr. Huff says these terms are not synonymous. The article should have stated that while doctors may use the terms "uncontrolled" and "poorly controlled" interchangeably, they are not synonymous, according to Huff. But the terms "uncontrolled" and "out of control" are synonymous, he says.
 
We regret the misquote, and we thank Dr. Huff for providing this information.