OASIS Alert

Learn the five fourth digits for 250.xx you should avoid.

The number of home care patients with diabetes continues to grow, so make sure you're coding correctly -- or you risk financially devastating medical reviews.

Diabetes is an underlying systemic disease, so you should code for it when it's documented that your patient has the condition, even if you don't have an active intervention planned, said coding expert Jill Young, with Young Medical Consulting in Lansing, Mich. during the Eli-sponsored audioconference "Diabetes: What do YOU need to know about 249.xx and 250.xx?"

Base your selection on the physician's documentation of these items, says Young:

• Type I versus Type II;

• Manifestations of the disease;

• Whether the current treatment regimen keeps the glucose levels within acceptable levels  (controlled versus uncontrolled); and

• Whether the patient is insulin-dependent.

Check your circulation: The fourth digit "7" indicates diabetes with peripheral circulatory disorders. Some coders see this code descriptor and think they can pair it with manifestations of coronary artery disease or cerebrovascular accident, says Trish Twombly, director of coding with Foundation Management Services in Denton, Texas. But the word "peripheral" is the key in this code description.

Peripheral circulatory disorders include peripheral vascular disease, angiopathy, and  gangrene, not cardiac circulatory conditions,Twombly says.

Aim high: While the ICD-9 code set includes 10 options for a fourth digit when coding for diabetes, there are three digits on the low end of the list that you're unlikely to list for a home health patient. These are:

• 250.1x (Diabetes with ketoacidosis);

• 250.2x (Diabetes with hyperosmolarity);

• 250.3x (Diabetes with other coma).

Typically, these codes indicate that a patient's diabetes is so out of control that he is in a coma. This patient would be more likely to be in the hospital than receiving home care, Twombly says. While these codes might be listed as a reason for hospitalization (M0190) or for a treatment regimen change (M0210), you wouldn't be likely to list them in M0230 or M0240, she says.

Veteran home care coders will remember the days when the only way to indicate a complication of diabetes was to list 250.9x. But when the ICD-9 code set was expanded to include the 10 fourth digits for 250.xx, "9" came to mean diabetes with an unspecified complication. This tells the intermediary that you don't know what your patient's complications are, Twombly says. Listing "9" in the fourth digit slot of 250.xx may be appropriate in acute care when labs aren't back, but when a patient arrives in home care, the complications should be well-documented.

Take a second look: You might automatically look to fourth digit "5" for 250.xx if your diabetic patient has cataracts. However, diabetic or snowflake cataracts are rare in Type II diabetes and your Type II diabetic most likely has senile cataracts, which aren't considered manifestations of diabetes.

One symptom of diabetes is burning, tingling, or numbness of the hands and feet or neuropathy. You would look to 250.6x (Diabetes with neurological manifestations) if your patient had this neurological condition.

When you look in your codebook under 250.6x you'll see 337.1 (Peripheral autonomic neuropathy in disorders classified elsewhere), but this isn't the code you need for a patient with diabetic polyneuropathy, Twombly says.

Code 337.1 indicates neuropathy of the heart, gut, and brainstem -- that's what "autonomic" indicates she explains. To code correctly for diabetic neuropathy, list 357.2 (Polyneuropathy in diabetes).