Home Health ICD-9/ICD-10 Alert

To indicate uncontrolled secondary diabetes, list the consequences.

As the 2009 codes went into effect on Oct. 1 you gained a whole new category for secondary diabetes. Brush up on this diagnosis to make sure you're using the new codes to the best effect.

Secondary diabetes is diabetes that is the result of another specific disease process, condition, or diabetes that develops when pancreatic tissue, which is responsible for producing insulin, is absent because it is destroyed by disease, said Jill Young, CPC, CPC-ED, CPC-IM of Young Medical Con-sulting during a recent Eli-sponsored audioconference, Diabetes ICD-9 Changes: What All Specialties Should Know.

Underlying causes of secondary diabetes can include Cushing's Syndrome, malignant neoplasm, genetic disorders, late effects of poisoning, or sepsis, Young said.

Tip: The most common cause of secondary diabetes in home care is steroid-induced diabetes.

As of Oct. 1, ICD-9-CM includes a new category of codes just for secondary diabetes. Codes in the 249.xx (Secondary diabetes mellitus) category are similar to the 250.xx (Diabetes mellitus) codes. However, you should note two big differences.

No case mix points: While diabetes codes in the 250.xx range can bring your agency additional case mix points, the 249.x secondary diabetes codes aren't case mix codes, 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.

In a surprise move, CMS did not include the 249 codes in the updated case mix list, Selman-Holman says. But secondary diabetes requires the same care and creates the same problems that diabetes coded with 250 causes.

However, CMS did add 249 to the pseudo-code appendix Table 3 Part 1, which means that you may gain points for certain manifestations of secondary diabetes, Selman-Holman says. For example, conditions such as peripheral autonomic neuropathy (337.1) and polyneuropathy (357.2) gain points when coded as manifestations after the 249 etiology.

No Type I or Type II: With codes in the 250.xx category, the fifth digit indicates which type of diabetes the patient has -- Type I or Type II -- as well as whether the diabetes is indicated as uncontrolled. But with the new 249.xx secondary diabetes codes, the fifth digit simply indicates whether or not the diabetes is stated as uncontrolled -- there's no Type I or Type II.

The guidelines for choosing between "not stated as uncontrolled" and "uncontrolled" are the same for 249 as they are with 250, Selman-Holman says. The physician must state the diabetes is uncontrolled or out of control before you can use the fifth digit for uncontrolled.

Sequencing is just as important for the 249.xx codes as it is with those in 250.xx. According to the Official Coding Guidelines effective Oct. 1, when you assign a code for secondary diabetes and a resulting manifestation, you must sequence the 249.xx code first. Follow this with the appropriate manifestation code and then the cause for the secondary diabetes.

Coding example: Your patient has secondary diabetes with diabetic nephrosis as the result of cystic fibrosis. You would assign 249.40 (Secondary diabetes mellitus with renal manifestations; not stated as uncontrolled or unspecified) first, followed by 581.81 (Nephrotic syndrome in diseases classified elsewhere) and 277.09 (Cystic fibrosis, with other manifestations).

But what if your focus of care is the underlying condition that causes the secondary diabetes? You'll still need to list the secondary diabetes before the manifestation, but your principal diagnosis (M0230) will be the cause of the secondary diabetes.

For patients who have developed secondary diabetes as a result of a pancreatectomy, report 251.3 (Postsurgical hypoinsulinemia).

Coding example: Your new patient had a Whipple procedure to treat pancreatic cancer located in the head of the pancreas. This surgical procedure treats pancreatic cancer by removing the head of the pancreas as well as parts of other nearby organs and tissues. As a result of this partial pancreatectomy, the patient developed hypoinsulinemia. You are providing surgical aftercare.

To code for this patient, list V58.42 (After-care following surgery for neoplasm), 157.0 (Malig-nant neoplasm of pancreas; head of pancreas), and 251.3. Do not report a code from the 249.xx category for secondary diabetes due to a pancreatectomy, but do list an additional code for any diabetic manifestations such as 581.81 for diabetic nephrosis, the guidelines advise.

Tip: Pancreatic cancer often recurs even after surgical removal, so code for it as present rather than using a V code to indicate a history of cancer.

If the diabetes is steroid-induced, you should include an E code to describe the intent of the drug use, Young said.

If the medical record indicates that the patient was taking the steroid as directed, you can report the appropriate 249.xx code, and E932.0 (Drugs, medicinal and biological substances causing adverse effects in therapeutic use; adrenal cortical steroids) as a secondary code.

But if the patient had an accidental overdose or took the wrong medication, resulting in steroid-induced secondary diabetes, you'll need to list 962.0 (Poisoning by hormones and synthetic substitutes; adrenal cortical steroids), followed by a 249.xx code and an E code to show the intent of the overdose: E858.0 (Accidental poisoning by other drugs; hormones and synthetic substitutes) or E950.4 (Suicide and self-inflicted poisoning by solid or liquid substances; other specified drugs and medicinal substances).

Don't forget: If your patient is taking insulin to control his secondary diabetes, be sure to report V58.67 (Long-term [current] use of insulin).