Home Health ICD-9/ICD-10 Alert

How to choose: First, check the physician's documentation to see what type of diabetes the patient has and if the condition is controlled. Then choose from one of the following fifth digits:

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
3 - Type I (juvenile type), uncontrolled

Example: If the patient you admit is an uncontrolled, Type II diabetic suffering from peripheral circulatory disorders, you would report 250.72 (Diabetes mellitus; diabetes with peripheral circulatory disorders; type II or unspecified type, uncontrolled).

Be careful: "The physician must specifically state 'uncontrolled' for you to choose a fifth digit of '2' or '3,'" Dilts-Benson warns.

3. Determine if diabetes is primary or secondary. Ask yourself if the diabetes is the most important reason you are providing home care, the most acute diagnosis and the reason for the most intense services, experts say.
 
Code what you are treating, not what you think caused the condition, stresses consultant Melinda Gaboury with Nashville, TN-based Health-care Provider Solutions. For example, even though diabetes may slow wound healing, you don't code it as primary for every patient you see with slow-to-heal wounds.

Because every diabetes case is different, there is no hard and fast rule regarding when the diabetesshould be the patient's primary or secondary diagnosis. "The nature of the presenting problem should govern the diagnosis code," advises Mary I. Falbo, president of Millennium Healthcare Consulting, Inc. in Lansdale, PA.
 
If you're in the home to manage congestive heart failure in a diabetic patient, the CHF is likely to go in M0230, not the diabetes - even though you get no extra points for CHF.

4. Mind your manifestations. Never use a manifestation code as the primary diagnosis. How-ever, you must list the manifestation code as the first secondary diagnosis for it to count in the case mix adjuster. Also, "include all the digits the coding rules require," says Sue Bowman, director of coding policy and compliance with the American Health Information Management Association.

Example: If your primary reason for providing care is for a diabetic ulcer on the heel, in M0230 you would code 250.8x (Diabetes mellitus with other specified manifestations) and then as the first diagnosis in M0240 you would code 707.14 (Ulcer of heel and midfoot). If you code only the 250.8x, your intermediary may deny your claim.

Mistake: If you are primarily caring for a foot ulcer in a diabetic patient, don't assume it's a diabetic ulcer, Dilts-Benson cautions. Be sure you have physician documentation before coding an ulcer as a diabetic manifestation.

Tip: Hyperglycemia is inherent in diabetes, and you do not need to code it separately.

5. Add V codes for insulin and pump use. Just as fourth and fifth digits help to paint a more complete picture of a patient's diabetes, and manifestation codes help to indicate the patient's specific conditions, V codes are important for telling the intermediary the whole story. Assign V58.67 (Long term [current] use of insulin) as a secondary code for patients who take insulin on a regular basis.

Caution: Even if you are in the home primarily to teach about insulin or monitor medication and glucose levels, you can't use V58.67 as primary, Bowman tells Eli. "The fact that the patient is on insulin would not be the reason for a healthcare encounter," she explains. Sequence the underlying diabetes diagnosis first, she instructs.

V codes also come into play for diabetes patients receiving their insulin via insulin pumps. Three V codes apply to different stages of the insulin pump treatment process: 

Tip: Use ICD-9 code 996.57 (Complication due to insulin pump) to report underdose of insulin due to insulin pump mechanical complications, followed by the appropriate diabetes code, based on documentation, the April 2005 ICD-9 Coding Guidelines instruct.

To code an overdose of insulin from a pump failure, first code 996.57, then 962.3 (Poisoning by insulins and antidiabetic agents), and then the appropriate diabetic code, the guidelines say.