ED Coding and Reimbursement Alert

Don't get tripped up on multiple conditions

Each time you choose a fourth and fifth digit for diabetes diagnosis code 250.xx, you may also need to select the appropriate code to identify the patient's specific diabetic manifestation.

Although the ICD-9 manual lists several possible manifestation code choices below each fourth-digit descriptor, you should realize that this is "definitely not an exhaustive list," says Alison Nicklas, RHIT, CCS, director of education and training for Precyse Solutions, based in King of Prussia, Pa.

For example, the ICD-9 manual lists 583.81 (Nephropathy) and 581.81 (Nephrosis) as possible manifestation codes below 250.4x (Diabetes with renal manifestations). But the manual doesn't list many possible renal manifestations of diabetes.

Avoid Pitfalls

Avoid coding pitfalls with these tips for five common diabetes complications:

1. Ketoacidosis: Diabetes' most serious acute metabolic complication is diabetic ketoacidosis (DKA), says Shelley Wojtasczyk, MS, FNP-C, a nurse practitioner in Arcade, N.Y. The acidosis complication also occurs in patients with chronic and acute alcoholism, she says. When coding for diabetic complications, be sure the medical chart states whether the patient has diabetic ketoacidosis.

Only one code: Don't worry about finding an additional code to identify the ketoacidosis as you would with other diabetic complications, Nicklas says. Code 250.1x specifies that the patient has diabetic ketoacidosis, and "that one code tells the whole story," she says.

2. Renal failure: Diabetic patients can have nephropathy, which usually leads to kidney failure, Wojtasczyk says.

If the physician's documentation indicates that the patient has chronic renal failure caused by diabetic nephrotic syndrome, all you really need to code is 250.4x and 585 (Chronic renal failure), says Nicklas, who presented in a March 11 audio seminar titled "Diagnosis Coding for Diabetes" for the American Health Information Management Association (AHIMA).

But if you prefer to code all three conditions, you can also list 581.81 (Nephrotic syndrome in diseases classified elsewhere), she adds.

3. Hypertension and renal failure: A diabetic patient may present with hypertension and renal failure as a result. If this is well documented, you may only need two codes, Nicklas says. Assign one code for the diabetes with renal manifestations (250.4x) and one code for the hypertension with renal failure (403.91).

You don't have to list any other code, because the hypertension code includes renal failure, she says. You can assign 583.81 (Nephritis and nephropathy) in addition, but remember that this is optional.

4. Cataracts: Many, but not all, diabetic patients have diabetic cataracts (commonly called snowflake cataracts), Nicklas says. "Studies have shown that most diabetics actually have the more common senile cataracts," she says. Snowflake cataracts are rare. Most physicians find them in diabetic patients, Wojtasczyk adds.

To report diabetic cataracts, the physician must document the diabetes as the cause. For diabetic cataracts, use 250.5x (Diabetes with ophthalmic manifestations) and 366.41 (Diabetic cataract).

However, for a diabetic patient with mature senile cataracts, use 250.0x (Diabetes mellitus without mention of complication) and 366.17 (Senile cataract; total or mature cataract). 

5. Gestational diabetes: Gestational diabetes affects women during late pregnancy, Wojtasczyk says. To report this condition, use 648.8x (Other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth or the puerperium; abnormal glucose tolerance). No code from the 250 series is necessary. 

For a woman who has an established diabetes diagnosis that is complicating her pregnancy, you should report 648.0x (Other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth or the puerperium; diabetes mellitus).