Home Health ICD-9/ICD-10 Alert

Assume a relationship between hypertension and chronic kidney disease.

When caring for a diabetic patient, you want to capture the case mix points your agency is due if diabetes is the focus of the care. But if you're not careful with your reporting, you could wind up being accused of upcoding. Find out how much is enough when reporting your patient's diabetic manifestations.

Real-life dilemma: Paloma Valenzuela, LVN, with Care Quality of El Paso, TX, wonders, "If I have a diabetic patient with multiple manifestations documented by the physician, do I have to code every single complicated diabetes code along with its manifestation, even though we are not doing anything for that specific manifestation?"

"For example, I have a patient whose primary focus of care is diabetes and anemia," Valenzuela says. "This patient also has hypertension and the renal manifestation of chronic kidney disease, a neurological manifestation of diabetic neuropathy, and the 'other manifestation' of a diabetic ulcer. Can I code for this patient as follows?"

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

• 285.9 (Anemia, unspecified);

• 401.9 (Essential hypertension; unspecified);

• 585.9 (Chronic kidney disease, unspecified);

• 250.80 (Diabetes with other specified manifestations; type II or unspecified type, not stated as uncontrolled);|

• 707.14 (Ulcer of heel and midfoot);

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

• 357.2 (Polyneuropathy in diabetes). 

Valenzuela also wonders, "Can these codes be in a different order as long as I state what those manifestations are?"

Key: When reporting care for a diabetic patient, you should always code for the diabetes regardless of whether any care is directed to the diabetes, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX. But, if certain diabetic manifestations are not pertinent to your plan of care, you do not have to include them.
 
If you're listing a diabetic manifestation diagnosis, the code for diabetes with the appropriate fourth digit should immediately precede the corresponding manifestations, Selman-Holman says. 

Problem: In the scenario above, there's no mention that the chronic kidney disease was a manifestation of diabetes, yet the suggested codes report it as such, Selman-Holman says. 

The sample sequencing indicates that diabetes is the focus of care, Selman-Holman says. However, anemia is not a manifestation of diabetes, so it cannot be sequenced second when you're using the fourth- digit "4" for renal manifestations. You should code for the specific renal manifestation -- chronic kidney disease -- next. 

Solution: If the chronic kidney disease is a manifestation of the patient's diabetes and assuming that this particular manifestation is the focus of care, you should sequence your codes as follows, Selman-Holman says:

• M0230a: 250.40 (Diabetes with renal manifestations; type II or unspecified type, not stated as uncontrolled);

• M0240b: 585.9 (Chronic kidney disease, unspecified);

• M0240c: 285.9 (Anemia, unspecified);

• M0240d: 403.90 (Hypertensive chronic kidney disease; unspecified; with chronic kidney disease stage I through stage IV, or unspecified);

• M0240e: 250.80 (Diabetes with other specified manifestions; type II or unspecified type, not stated as uncontrolled);

• M0240f: 707.14 (Ulcer of heel and midfoot);

• Other pertinent diagnoses: 250.60 (Diabetes with neurological manifestations; type II or unspecified type, not stated as uncontrolled); and 357.2 (Polyneuropathy in diabetes).
 
When a patient has both chronic kidney disease and hypertension, assume the two conditions are related. You should report the hypertension with a code from the 403.x (Hypertensive chronic kidney disease) category instead of using one from the 401 (Essential hypertension) category. 

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. Check with your fiscal intermediary for guidance if this is the case.