Ophthalmology and Optometry Coding Alert

When a patient presents with diabetic retinopathy, ICD-9 instructs coders to code the patient's eye condition and the patient's type of diabetes but this isn't a steadfast rule for many carriers.

Most Medicare carriers don't require that you code the type of diabetes, but other carriers may be singing another song. If your carrier does require you to code the systemic condition of diabetes, it is imperative to code to the highest level of specificity.

Diabetes affects the retina by making small blood vessels thicker, weaker, and more prone to deformity and leakage in both insulin-dependent patients and non-insulin-dependent patients, according to Principles of ICD9 Coding . Because of the affect of diabetes on the eyes, it is important to attribute retinopathy to diabetes when applicable.

To code the diagnosis of diabetic retinopathy, start by looking up the condition or disease process present, in this case, "retinopathy," in the alphabetical index. Scan the subclassifications to locate the modifier "diabetic" that further defines the patient's condition. Notice that four codes are listed, two for diabetic retinopathy and two for proliferative diabetic retinopathy. The codes in brackets are the secondary codes, which means the code for the patient's diabetes should be listed first as the primary diagnosis. Turn to the applicable code (depending on the documentation, either 362.01 or 362.02) in the tabular list. In the tabular list, you are directed to 250.5, where you are to choose the appropriate diabetes code first, from the 250.5 category.

If you turn to 250.5, you will find the category of diabetes with ophthalmic manifestations. The category is preceded by a fifth-digit indicator. Use the table of fifth digits listed under the subhead 250 "Diabetes mellitus" to choose the appropriate fifth digit:

So, if an insulin-dependent, juvenile-type patient with controlled diabetes presents with diabetic retinopathy, the patient's condition of diabetes would be coded 250.51.
After you have assigned a fifth digit to 250.5x, it is time to choose the appropriate secondary code for the diabetic retinopathy. Turn back to 362.0x and choose between background diabetic retinopathy, 362.01, and proliferative diabetic retinopathy, 362.02.