Home Health ICD-9/ICD-10 Alert

Do you know when it's safe to list diabetes as primary?

Cheat sheet: Look for a physician's statement about the cause of a potential manifestation. If you can't find one, it's not always safe to assume diabetes is the culprit. For instance, you can assume your patient's osteomyelitis or gangrene is a manifestation of diabetes and code for it accordingly -- but only if the physician hasn't pointed to another cause for those conditions.With other conditions, however, you'll need the physician to link the co-morbidity to diabetes before you can code for it as a manifestation.

Bottom line: With a diabetic patient, you must show a physician-verified cause-and-effect link before you can code any other co-morbidities as manifestations.

Look to the fourth digit: Once you've established that a condition is a manifestation, you'll use the fourth digit to show that diabetes is the underlying reason. "The fourth digit links the complication to the diabetic diseases," says Joan L. Usher, BS, RHIA, COS-C, ACE, with JLU Health Record Systems in Pembroke, Mass.

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. Listing "6" as the fourth digit indicates that the neuropathy is a neurological manifestation of diabetes.

Tip: When looking up a fourth digit primary diabetes code, make sure to also include the bracketed code for the manifestation. Notes following diabetes codes 250.4-250.8 remind you to "use additional code to identify manifestation as..."

When reporting care for a diabetic patient, you should code for the diabetes, provided your documentation shows how this condition impacts the plan of care, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas. However, you needn't list all of a patient's diabetic manifestations if some aren't pertinent to your plan of care.

Coding scenario: Your focus of care is your patient's diabetic chronic kidney disease and anemia. He also has hypertension and the neurological manifestation of diabetic neuropathy, plus the "other diabetic manifestation" of a diabetic ulcer on the foot. How would you code for him? And how would you sequence his manifestations? Code for your patient as follows, Selman-Holman says:

• M1020a: 250.40 (Diabetes with renal manifestations; type II or unspecified type, not stated as uncontrolled);
• M1022b: 403.90 (Hypertensive chronic kidney disease; unspecified; with chronic kidney disease stage I through stage IV, or unspecified);
• M1022c: 585.9 (Chronic kidney disease, unspecified);
• M1022d: 285.9 (Anemia, unspecified);
• M1022e: 250.80 (Diabetes with other specified manifestations; type II or unspecified type, not stated as uncontrolled);
• M1022f: 707.14 (Ulcer of heel and midfoot); and
• Other pertinent diagnoses: 250.60 (Diabetes with neurological manifestations; type II or unspecified type, not stated as uncontrolled); and 357.2 (Polyneuropathy in diabetes).

You should sequence the patient's diabetic chronic kidney disease and his anemia early on in your list of diagnosis codes because that's the focus of your care, Selman-Holman says. Anemia is not a manifestation of diabetes, so you can't sequence it second on your list when you're reporting a diabetes code with the fourthdigit "4" to indicate renal manifestations. You will need additional information to code a more specific type of anemia, such as anemia associated with chronic kidney disease (285.21), she says.

Safe to assume: When a patient has both chronic kidney disease and hypertension, you can assume the two conditions are related, Selman-Holman says. You should report the hypertension with a code from the 403.x (Hypertensive chronic kidney disease) category instead of using one from the 401.x (Essential hypertension) category.

But when the documentation indicates that your patient has diabetic chronic kidney disease and also hypertension, the sequencing is different. In this case, you have two conditions contributing to the third, Selman-Holman says. The AHA's Coding Clinic for ICD-9-CM indicates in this case that you should sequence the codes in the following order: 250.4x, 403.xx and then 585.x. Some coders "panic" when they see the 585.x code separated from the diabetes code, but remember that chronic kidney disease is not a true manifestation -- it does not appear in italics in your ICD-9 manual, Selman-Holman points out.

Code for the diabetic manifestations of neuropathy and ulceration with respective fourth digits "6" and "8" next in the example scenario. Sequence the manifestation that best supports the plan of care first. In the example, the diabetic ulcer is sequenced before the diabetic polyneuropathy based on the assumption that more effort would be expended on the plan of care for the ulceration.

Warning: If the diabetic renal disease and the anemia are related to dialysis, the care you are providing related to these diagnoses may not be covered by the Medicare home health benefit, Selman-Holman says. Services that are covered under the ESRD program and that are contained in the composite rate reimbursement methodology, including any service furnished to an ESRD beneficiary that is directly related to that individual's dialysis, are excluded from coverage under the Medicare home health benefit.

Resource: See the Medicare Benefit Policy Manual Chapter 7, Home Health Services 80.5, Services Covered Under End Stage Renal Disease (ESRD) Program for more information.