Home Health ICD-9/ICD-10 Alert

Diabetic manifestations don't always require two codes.

Knowing how to code correctly for diabetes will save you time and could earn your agency case mix points. Follow these simple steps to make sure you're on the money.

1. Which type? Primary diabetes has two types: Type I and Type II. Type I is the more serious of the two because the patient's pancreas has completely stopped producing insulin, says Trish Twombly, RN, BSN, HCS-D, CHCE, director of coding with Foundation Management Services in Denton, Texas. Type II, on the other hand, is a metabolic condition. This type of diabetes begins with cells that have become resistant to insulin, rather than with a pancreas that isn't producing insulin. The cells just can't use the insulin properly, Twombly says.

Terminology update: Type I used to be referred to as "insulin-dependent" diabetes, and Type 2 was called "non-insulin-dependent" diabetes. But these terms have become outdated. Now, Type I is called "juvenile onset." Type II used to be known as "adult onset," but that term is also antiquated.

Coding tip: If the medical record doesn't specify which type your patient has, the official coding guidelines require you to default to Type 2.

2. Is it uncontrolled? When you select the fifth digit for primary diabetes using a 250.xx (Diabetes mellitus) code, you're indicating whether the patient has Type I or Type II, and whether the diabetes is stated as uncontrolled or not stated as uncontrolled.

Only the physician can state whether the diabetes is uncontrolled, Twombly says. Therapists and clinicians cannot make this decision. So the only time you can code as uncontrolled is when it's in the physician  documentation.

Keep in mind: "Out of control" indicates uncontrolled diabetes; "poorly controlled" does not, Twombly says.

3. What are the manifestations? Diabetic patients often develop manifestations of the condition. But you can't assume that all co-morbidities are diabetic manifestations.

Safe to assume: There are only two conditions that you can assume are manifestations of diabetes when they appear in a diabetic patient: osteomyelitis and gangrene, Twombly says. But you can only make this assumption if the physician doesn't state another cause for the osteomyelitis and gangrene. All other conditions must show a physician-verified cause-andeffect link to be coded as manifestations.

You'll use the fourth digit to indicate whether a patient has a manifestation of diabetes. Fourth digits range from 0 to 9 and are broken down into physiological categories, such as neurological, renal, and ophthalmic. You must decide which category your patient's manifestation falls under and then code for that condition.

Coding example: Your new patient has diabetes and diabetic neuropathy. When you look up neuropathy in the alphabetic index, the slanted brackets around code 357.2 (Polyneuropathy in diabetes) indicate that you have found a manifestation code, so this cannot be the first code you list. Mandatory multiple coding rules require you to list the underlying condition (diabetes in this case) first.

So you'll list 250.6x (Diabetes with neurological manifestations) right before 357.2, Twombly says. Listing "6" as the fourth digit indicates that the neuropathy is a manifestation of diabetes.

Tip: When looking up a fourth digit primary diabetes code, make sure to also include the bracketed code for the manifestation.

You'll code for primary diabetes with a 250.xx code, but for diabetes caused by another condition or event, look to the 249.xx (Secondary diabetes mellitus) series. Causes for secondary diabetes include cystic fibrosis and long-term steroid use.

You'll choose the fourth digit for a 249.xx code based on whether the patient has a diabetic manifestation and which type, Twombly says. But when you get to the fifth digit for secondary diabetes, there is no Type I or Type II. The fifth digit only indicates whether the secondary diabetes is not stated as uncontrolled or is uncontrolled.

As a general rule of thumb, coding for a diabetic manifestation requires at least two codes, but sometimes you'll use more, and sometimes you'll use fewer. Watch for the following conditions:

• Osteomyelitis. If your diabetic patient has osteomyelitis, you can assume it's a diabetic manifestation, but it takes three codes to fully report this situation. You'll need to include 250.80 (Diabetes with other specified manifestations; type II or unspecified type, not stated as uncontrolled), 731.8 (Other bone involvement in diseases classified elsewhere), and a code from 730.xx (Osteomyelitis, periostitis, and other infections involving bone), says Jan McLain, RN, BS, LNC, COS-C, HCS-D, with Adventist Health System Home Care in Port Charlotte, Fla.

However, other diabetic manifestations -- such as diabetic hypoglycemia or hypoglycemia shock -- coded with 250.80 don't require additional codes, McLain says. There's also no need to report a second code for the manifestation with diabetic ketoacidosis (250.1x), diabetic hyperosmolarity (250.2x), or diabetic hyperglycemic coma or insulin coma (250.3). Note: you won't likely report these codes in M0230/240, but they may appear in M0190 (Inpatient diagnoses) or M0210 (Medical diagnoses requiring changed medical or treatment regimen).

• Visual manifestations. If the patient has visual impairment or visual manifestation of diabetes, it could take up to three codes to report, McLain says. For a patient with diabetic macular edema, you would need to report 250.50 (Diabetes with ophthalmic manifestations; type II or unspecified type, not stated as uncontrolled), 362.0x (Diabetic retinopathy), and 362.07 (Diabetic macular edema).