Internal Medicine Coding Alert

Hint: The fourth digit is key to payment

To submit solid diabetes claims, you should know how to report a diabetic patient's complications by selecting the correct fourth digit for 250.xx, plus the corresponding complication codes. Our experts show you how.

You can list them all: Your internist's diabetic patients can have one or multiple diabetic complications and chronic manifestations.

Therefore, you should report multiple complications by listing multiple 250.xx codes with the appropriate fourth digits, says Alison Nicklas, RHIT, CCS, director of education and training for Precyse Solutions, based in King of Prussia, Pa. (For more information, see "5 Examples Tie Diabetes Complications to ICD-9 Codes".)

For example, if a Type II, uncontrolled diabetic patient has four chronic manifestations -- renal, ophthalmic, neurological and circulatory -- you can actually list 250.42, 250.52, 250.62 and 250.72, along with the corresponding manifestation codes, such as 581.81 (Nephrotic syndrome) and 366.41 (Diabetic cataract).

Code 250.xx is primary: Always code the diabetes first and report the chronic manifestation code as the secondary diagnosis, says Anita Carr, CPC, business office manager and assistant practice manager for Endocrine and Diabetes Associates in Louisville, Ky.

In outpatient settings, you seldom need to list all the patient's chronic manifestations. Instead, list the manifestations the internist treats on a given visit. When the physician sees inpatients, however, the physician will likely treat all of the patient's manifestations.

In such cases, report all the appropriate codes, says Elaine Rehmer, CPC, an administrator at Cosmopolitan Diabetes Center in Columbia, Mo.

Remember this: The physician must clearly identify that the diabetes has caused a patient's complication or chronic manifestation.

The code descriptors in the ICD-9 manual can be confusing because they use the word "with" (e.g., "Diabetes with renal manifestations"), leading some coders to assume that there doesn't need to be a causal connection between the complication and the diabetes, Nicklas says. Be careful not to assume anything.

The documentation must define a condition as a diabetic complication or manifestation for it to be coded as such, she adds.