Home Health ICD-9/ICD-10 Alert

Adult onset isn't always an accurate description of type II diabetes.

If you're not using the right fourth and fifth digits for code 250.xx when reporting services for your diabetic patients, you're not following ICD-9 coding guidelines--and you could risk losing a whopping 17 case-mix points.

Fact: 20.8 million Americans have diabetes, according to the national diabetes fact sheet created by the Centers for Disease Control and Prevention, the National Institutes of Health, and the American Diabetes Association. And the incidence of diabetes in the United States has risen sixfold over the past 50 years, says Sheri Poe Bernard, CPC, CPC-H, CPC-P, on the clinical staff at Ingenix Inc.

The big three: To make sure you're coding diabetes correctly, you'll need to know three pieces of information: which type of diabetes your patient has, whether the diabetes is uncontrolled, and whether your patient has any manifestations that are related to his or her diabetes.

1. Determine whether the diabetes is type I or type II. Type I diabetes, also known as juvenile-type, is the result of autoimmune destruction of the pancreatic beta cells which causes insulin production to cease, says Deborah J. Grider, CPC, CPC-H, CPC-P, CCS-P, EMS, president of Medical Professionals Inc. in Indianapolis. These patients require regular insulin injections, she says.

Type II diabetes, also called adult-onset diabetes, is caused by the body's inability to respond to insulin that is produced, Grider says.

The term "adult-onset" has become a bit of a misnomer as more and more children have type II diabetes because of obesity, diet and lifestyle, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX. Coders can no longer assume that a child with diabetes has type I, juvenile diabetes, she says.

Reality: 90 percent of diabetes in the United States is type II, Bernard says.

Follow the rule: If the type of diabetes is unspecified, ICD-9 coding conventions require you to report a type II code if you are unable to get details from the clinician who documented the diabetes.

The terms "insulin-dependent diabetes (IDDM) "for type 1 and "non-insulin dependent diabetes (NIDDM)" for type II were removed from ICD-9 code descriptions in 2005, notes Grider. While NIDDM is generally type II, it doesn't follow that all patients documented as IDDM are type I, Bernard says. Some type II diabetics require insulin for good control of the condition, she says.

2. Know whether the diabetes is uncontrolled. To code for uncontrolled diabetes, you must have physician documentation stating the diabetes is uncontrolled. Don't assume you can select an uncontrolled code based on a high blood glucose reading or if the physician says the diabetes is "poorly controlled," Bernard cautions.

Poorly controlled means the patient's diabetes is controlled, although poorly, Selman-Holman says. You should query the physician when you see this statement in the medical record, she says.

You might argue that you should be able to state whether a patient's diabetes is uncontrolled or not, Selman-Holman says. After all, you're checking the blood sugars, you know whether the patient is compliant with his diabetic instructions, and you set parameters for those blood sugars on the plan of care, she notes. But only the physician can state that the patient's diabetes is uncontrolled, she says.

When you know which type of diabetes your patient has and whether it's uncontrolled, you can select your fifth digit from the following options:

• 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); or
• 3 (type I [juvenile type], uncontrolled).

Additional code: When reporting a fifth digit of "0" or "2" for a type II diabetic who routinely uses insulin to control his diabetes, you should also report V58.67 (Long-term [current] use of insulin) as a secondary diagnosis.
 
But don't report V58.67 when temporarily using insulin to bring sugars down during an encounter, Bernard cautions. And don't report V58.67 for a type I diabetic, she says.

With your fifth digit determined, you're ready to figure out the correct fourth digit for your patient.

3. Indicate whether your patient has any diabetic manifestations. Chose 0 (... without mention of complication) for diabetes without any related complications. Don't use this code if your patient has any diabetic manifestations, warns Lynn Yetman, RN, MA, HCS-D, COS-C, LNC, of Reingruber & Company in St. Petersburg, FL.

But even if you're not actively treating the diabetes, you should report that the patient has it, Yetman says. Three conditions--diabetes, hypertension and CAD--should always be reported, even if they aren't a focus of care, she explains.

Choose a fourth digit from 1 through 8 for patients with diabetic manifestations.

Don't overlook: Several diabetic manifestations require two codes. When reporting them, you'll typically list the diabetes code for the type of manifestation your patient has, followed by a code for the specific manifestation, Grider says.

When reporting multiple diabetic manifestations, pair each with the appropriate diabetes code,  Bernard says. For example, if your type II diabetic patient has diabetic nephropathy, gastroparesis resulting from diabetes, and diabetic peripheral vascular disease, you would code for them as follows, she says:

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

• 583.81 (Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere);

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

• 536.3 (Gastroparesis);

• 250.70 (Diabetes with peripheral circulatory disorders; type II or unspecified type, not stated as uncontrolled); and

• 443.81 (Peripheral angiopathy in diseases classified elsewhere).

Tip: Avoid using fourth digit 9 (Diabetes with unspecified complication), Bernard says. Unspecified codes like these are more appropriate in an emergency department setting or for a patient in transit, when the details of the manifestation may not become known during the encounter, she says.

Look out: Using 250.9x also draws the attention of your intermediary because it indicates that you may not have enough information to support the use of the diabetes code, Selman-Holman says. This is especially true if you have coded diabetes as primary and expect to gain the corresponding 17 points as a case mix diagnosis, she says.