OASIS Alert

Can Type II diabetics have diabetic cataracts?

250.02 (Diabetes mellitus without mention of complication; type two or unspecified type, uncontrolled) indicates a patient whose diabetes is uncontrolled, but with no identified manifestations, says Trish Twombly, BSN, RN, HCS-D, CHCE, COS-C, director of coding with Foundation Management Services in Denton, Texas.

Caution: Some will warn against using 250.0x as a primary diagnosis, but you can list a 250.0x (Diabetes mellitus without mention of complication) code as your principal diagnosis. List 250.0x in M1020 when your focus of care is:

• Newly diagnosed diabetes without manifestations
• Diabetes progressing from an oral hypoglycemic medication to insulin

250.0x is also appropriate when the patient has diabetes and you suspect manifestations but the physician will not confirm the conditions as manifestations, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas.

Also: Don't be afraid to list 250.0x as a secondary diagnosis when the patient's diabetes impacts the care you provide.

Mistake: Listing 1, 2, or 3 as the fourth digit of your diabetes code.

250.1 (Diabetes with ketoacidosis), 250.2 (Diabetes with hyperosmolarity), and 250.3 (Diabetes with other coma) are uncommon diagnoses in home care, Twombly says. It would be unusual to list them in M1020 or M1022.

However, these codes may be appropriate to list in M1010 (Inpatient diagnosis) or M1016 (Diagnoses requiring medical or treatment regimen change in past 14 days), Twombly says. These codes indicate metabolic complications that do not require a corresponding manifestation code.

Although diabetes is the number one cause of kidney failure in the United States, there is no assumed relationship between these conditions in ICD-9-CM, Twombly says.

If the physician hasn't documented the diabetes as the cause of the kidney disease, you must code it separately and not as a diabetic manifestation, using a 250.0x for the diabetes. Listing 250.4x (Diabetes with renal manifestations) indicates that you have a documented causal link between the two conditions.

Test yourself: If your new patient has diabetes with renal manifestations documented by the physician and  is receiving dialysis, can you list 250.4x in M1020 and 585.6 (End stage renal disease) in M1022? Yes, as long as diabetes is the focus of care and the CKD is the only known manifestation. Remember that ESRD (585.6) as a primary diagnosis will attract unwanted attention from the regulators because the dialysis benefit covers ESRD. Documentation should reflect diabetes as the focus of care to substantiate diabetes as primary, Selman-Holman says.

Mistake: Listing 250.50 or 250.52 and 366.41 for diabetic cataracts is usually a mistake but not always.

Diabetic cataracts are more common in type 1 diabetics and rare in type 2 diabetics. If diabetics have cataracts, they are usually senile type and not diabetic cataracts. Selman- Holman says. Just be aware that reporting 250.50 or 250.52 (Diabetes with ophthalmic manifestations) and 366.41 (Diabetic cataract) may attract attention because of the rarity.

Patients with diabetic neuropathy experience burning and tingling of the hands and feet. This condition is properly coded with 250.6x (Diabetes with neurological manifestations) and 357.2 (Polyneuropathy in diabetes).

However, coders frequently make the error of reporting 337.1 (Peripheral autonomic neuropathy in disorders classified elsewhere) for peripheral neuropathy even though the assessment describes burning and tingling in the extremities. The code 337.1 actually describes neuropathy in the peripheral autonomic nervous system of a diabetic patient.

Autonomic neuropathy affects the nerves that control the heart, regulate blood pressure, and control blood glucose levels. Autonomic neuropathy also affects other internal organs and can cause digestion problems and difficulties with respiratory function, as well as problems with urination, sexual response, and vision. Patients with diabetic neuropathy may also experience problems with their blood glucose regulation systems which can result in the absence of hypoglycemia warning signs.

250.7x (Diabetes with peripheral circulatory disorders) doesn't refer to heart-related manifestations, Twombly says. Instead, pair peripheral circulatory disorders like gangrene (785.4) or diabetic peripheral vascular disease (443.81) with 250.7x.

Listing 250.9 (Diabetes with unspecified complication) was once a way to indicate that your patient haduncontrolled diabetes, Selman-Holman says. But changes to the diabetes code set years ago added fifth digits to specify uncontrolled and not stated as uncontrolled. Now, reporting 250.9x says "I have a patient with diabetic complications, but I don't have a clue what they are," Twombly says. "That really shouldn't happen in home care. Either you know the manifestations or you don't," Selman-Holman adds.