Home Health ICD-9/ICD-10 Alert

Hint: Look beyond 250.xx for secondary diabetes.

Diabetes is one of the most common diagnoses you'll report as a home care coder. But reporting it frequently doesn't mean choosing the right codes is an easy task. Learn how you can select the right code every time in three easy steps.

In the 250.xx (Diabetes mellitus) category, each code must include five digits, or it's not considered a valid code. The fifth digit indicates whether the diabetes is type I or type II and whether it's stated as uncontrolled.

You have four fifth digits to choose from:

• 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); and

• 3 (type I [juvenile type] uncontrolled).

If the medical record doesn't specify what type of diabetes your patient has, the default fifth digit is "0," says Jun Mapili, PT, MAEd, coding supervisor and director of rehabilitation with Global Home Care in Troy, MI.

Check the record: Before you list a patient's diabetes as uncontrolled, you must have physician documentation -- the assessing clinician can't make this determination, says Trish Twombly, RN, BSN, HCS-D, CHCE, director of coding with Found-ation Management Services in Denton, TX.

Remember: Manifestations, problems with diabetes and complications don't necessarily mean a patient's diabetes is uncontrolled, Twombly points out. The Centers for Medicare & Medicaid Serv-ices considers such conditions expected outcomes from a long-term disease.

The fourth digit indicates whether your patient has a diabetic complication and indicates the type of complication.

If your patient doesn't have any diabetic manifestations, or they have manifestations but information isn't available for you to code the manifestation as caused by diabetes, you'll list fourth digit "0" (Diabetes mellitus without mention of complication).

If your patient has a manifestation of diabetes, you'll need to select the correct fourth digit for that type of manifestation. These include the following codes common in home care:

• 4 (... renal manifestations);

• 5 (...ophthalmic manifestations);

• 6 (... neurological manifestations);

• 7 (... peripheral circulatory disorders);

• and 8 (...other specified manifestations).

Just as when deciding whether to list diabetes as uncontrolled, you must have clear documentation when coding a condition as a manifestation of diabetes. For example, just because a diabetic patient has chronic kidney disease doesn't mean you can assume the diabetes caused the CKD, Twombly says.

You must have documentation showing a cause and effect relationship between the diabetes and the manifestation, Twombly says. If the record shows that the patient or the patient's family indicates a condition as a manifestation of diabetes, verify with the physician whether you should code for it as such.

Exceptions to the rule: There are two conditions that you can assume are complications of diabetes when they occur in a diabetic patient, Twombly says. These are osteomyelitis and gangrene. For a diabetic patient with osteomyelits, you would list fourth digit "8" for other specified manifestations, while fourth digit "7" for peripheral circulatory disorders is the right choice for a patient with gangrene.

If your diabetic patient does have a true manifestation of diabetes, you must sequence the etiology (diabetes) first, followed by the manifestation when reporting the diagnosis codes.

Coding example: Your patient has type II diabetes and gangrene. For these conditions, you would first list 250.70 (Diabetes with peripheral circulatory disorders; type II or unspecified type, not stated as uncontrolled) followed by 785.4 (Gang-rene).

Caution: These sequencing guidelines hold true even if the manifestation of diabetes is the reason you are seeing the patient. In that case, you would list the diabetes code in M0230a, followed by the manifestation code in M0240b.

When your patient has multiple diabetic manifestations, you may need to list multiple 250.xx codes, Twombly says. If you find yourself changing the fourth digit to accommodate a manifestation, then you need to list an additional 250.xx code.

Coding example: Your type II diabetic patient has both diabetic neuropathy and mild nonproliferative diabetic retinopathy. To code for this patient's diabetic conditions, you would need to list:

• 250.60 (Diabetes with neurological manifestations; type II or unspecified type, not stated as uncontrolled);

• 357.2 (Polyneuropathy in diabetes);

• 250.50 (Diabetes with ophthalmic manifestations; type II or unspecified type, not stated as uncontrolled);

• 362.04 (Mild nonproliferative diabetic ret-inopathy).

Know when to list V58.67. Listing V58.67 (Long-term [current] use of insulin), is only appropriate for patients with type II diabetes who take insulin, Twombly says. This code is used to gather statistics about type II diabetics who use insulin regularly, so it's incorrect coding to list the code for type I diabetics.

Don't list a 250.xx code for steroid-induced diabetes. Even though the medical record specifies that a patient has steroid-induced diabetes, coders frequently list a code from the 250.xx category rather than 251.8 (Other specified disorders of pancreatic internal secretion), the correct code for steroid-induced diabetes when the steroid has been correctly prescribed and administered.

Watch for changes: Come Oct. 1, secondary diabetes -- such as steroid-induced diabetes -- will have its own range of codes (249.00-249.91). The manifestations for secondary diabetes will mimic the manifestations under 250.xx.