OASIS Alert

If your home health agency continues to grapple with diagnosis coding for patients with diabetes, you're not alone. Diabetes coding is a major stumbling block for many agencies.

And diabetes coding mistakes not only can shatter your compliance record, they also can hit you directly in the wallet.

Three main areas of diabetes coding present problems for HHAs, experts tell Eli:

1. Undercoding. Agencies tend to fall short of the coding mark when facing diabetes with another manifestation, says consultant Prinny Rose Abraham with HIQM Consulting in Minneapolis. Whenever you use codes 250.4 through 250.8 (diabetes with renal manifestations, ophthalmic manifestations, neurological manifestations, peripheral circulatory disorders and other specified manifestations, respectively), you must use an additional code to identify the manifestation, she instructs.

The Centers for Medicare & Medicaid Services addresses this issue in the 28-page coding guidance issued last September, using diabetic ulcers as an example. In this case, you would use code 250.8x (filling in the appropriate fifth digit for 'x'), followed by code 707.9 (chronic ulcer of unspecified site) in brackets. "Placed in brackets, the second code is a manifestation of the disease diabetes," the guidance says.

Many agencies neglect to include the manifestation codes because they rely on computer programs that will accept 250.8 as a stand-alone code and don't "alert them that there are additional coding requirements," Abraham explains. Further, agencies often fail to realize the instructional statements included in the ICD-9 coding book "aren't optional they're coding rules," she notes.

2. Code sequencing. "Problem number two is knowing when to sequence diabetes first," Abraham reports. When a patient has diabetes with another manifestation, such as diabetic neuropathy, the coding guidelines mandate that agencies code the diabetes first, notes consultant Joan Usher with JLU Health Record Systems in Pembroke, MA.

If a patient has multiple manifestations, agencies should code for each one, she adds. "People are confused that you can sometimes use more than one 250 code," Usher says. Remember that since the fourth digit is different, the codes represent different conditions, she instructs. And when you have to use multiple 250 codes, list the most acute condition first and go from there, Usher advises.

CMS' coding guidance offers the following example of how to code for diabetes with multiple manifestations: "A 79 year old patient has uncontrolled diabetes type 1. She is legally blind and has diabetic retinopathy. Other diagnoses are congestive heart failure, peripheral vascular disease due to diabetes, and pleural effusion The skilled nursing services include wound care to the chronic diabetic ulcer on the left foot; prefill syringes, administer insulin every day, fingerstick every week and PRN for signs and symptoms of hypo/ hyperglycemia; teach diabetic foot care regimen; and monitor medication regimen."

In this case, CMS says the agency should code as follows: 250.83 (diabetes with other speciied manifestations);707.15(diabeticulcer);250.73 (diabetes with peripheral circulatory disorders); 443.81 (peripheral vascular disease due to diabetes); 250.53 (diabetes with ophthalmic manifestations); 362.01 (diabetic retinopathy); 428.0 (congestive heart failure); 511.9 (unspecified pleural effusion); and 369.4 (legal blindness).

Agencies also get confused because they assume that if they code diabetes first, that means they're saying diabetes is the primary reason for home care, says Abraham. But that's not the case. "It means of the two codes required to describe the condition, this one goes first," she explains. For example, if the primary purpose of the home care is to care for a diabetic ulcer and not the actual diabetes, you still must code the diabetes first and the ulcer second, Usher says.

3. Physician documentation. The fifth digit often is problematic for agencies, Abraham relates. "When you read the fifth digit subclassification, it specifically says 'stated as uncontrolled,'" she notes. That means you must have physician documentation that supports the code, she instructs.