OASIS Alert

Hint:  Insulin is not the answer to the type question.

After years as a clinician, you may think you know about diabetes, but old-fashioned thinking can lead to M0230 and M0240 coding errors.

If you haven't been paying close attention to the details of the last few ICD-9 coding changes, you may have missed the explanation of diabetes types. "The descriptors for diabetes codes no longer make reference to insulin use or non-use," advises coding consultant Lisa Selman-Holman with Denton, TX-based Selman-Holman & Associates.

This change could lead to errors for clinicians who use the insulin connection to determine the type of diabetes the patient has, she explains. Instead, how well the patient's pancreatic beta cells are functioning determines the diabetes code's fifth digit.

Reality: Type I diabetes is relatively rare compared to Type II diabetes. "Statistics demonstrate that only 5 to 10 percent of all diabetics have Type I diabetes," which is an autoimmune disorder, says certified coder Alison Nicklas, director of education and training for King of Prussia, PA-based Precyse Solutions.

Look to the ICD-9 coding guidelines for clear explanations of types of diabetes you may encounter. Don't base the type on whether the patient uses insulin. While all Type I patients must use insulin, many Type II patients do also.  The guidelines stress these points:

• You must use a fifth digit for all 250.xx diabetes codes.

• Default to Type II if the type of diabetes is not documented in the medical record. Do not base your decision on the age of onset or the use of insulin.

• If your Type II patient routinely uses insulin, include code V58.67 (Long term [current] use of insulin) to indicate this.

• Do not include code V58.67 if the Type II patient is using insulin temporarily to bring blood sugar under control.

• For a patient who was not previously diabetic, but develops diabetes during a current pregnancy (gestational diabetes), use code 648.8x (Other current conditions in the mother classifiable elsewhere but complicating pregnancy, childbirth, or the puerperium; abnormal glucose tolerance) and choose the fifth digit (0-4) to indicate when the condition or complication occurred.

Tip: Include V58.67 if the physician is treating the gestational diabetes with insulin, says Nancy L. Reading, CEO of Cedar Edge Medical Coding and Reimbursement in Centerfield, UT. For pregnant women who are diabetic before becoming pregnant, you should assign 648.0x (Other current conditions in the mother classifiable elsewhere but complicating pregnancy, childbirth, or the puerperium; diabetes mellitus), and then the appropriate 250.xx code to identify the type of diabetes, Reading advises. You should never report 648.0x and 648.8x together, she adds.

How To Code Two Rarer Types

Watch for: Some physicians are now identifying Type 1.5 diabetes, coders report. This is considered to be a latent autoimmune disorder--sometimes called a slow acting Type 1 diabetes--with incomplete beta cell destruction and no component of insulin resistance. Experts suggest you assign Type I diabetes to a patient with Type 1.5, because Type 1.5 is a latent autoimmune condition and Type I is essentially an autoimmune disorder. This means you should select from fifth digits "1" and "3" in the 250.xx series.

Another snag: Secondary diabetes is not coded under series 250. Underlying diseases, medicines or chemicals many cause secondary diabetes, such as pancreatitis or cancer of the pancreas, alcoholism or a number of commonly used medications, medical experts explain. The code for secondary diabetes is 251.x (Other disorders of pancreatic internal secretion).

Caution: The diabetic whose diabetes was induced by steroid use--and who now has the same care as any other diabetic--will not receive the extra points, because only the 250 code provides points, Selman-Holman warns.