Part B Insider (Multispecialty) Coding Alert

Leaving out diabetic complication codes could hurt your cash flow

If you're not reporting the right fourth and fifth digits on 250.xx, you may be undermining patient complexity and thereby billing for lower-level services than your physician provided.

Patients with diabetes often suffer from one or multiple complications that require extra attention and consideration from the physician, and these added complications can have a significant effect on the E/M level you bill. Use these six steps for definitive diabetes diagnosis coding to ensure that your ICD9 Codes justify the services you bill.

1. Select Fourth Digit First

Coders must determine the fourth digit for 250.xx (Diabetes mellitus) according to the type of diabetic complication the patient suffers from, if any. Diabetes patients may suffer from more than one complication, and if this is the case you should code only the complication relevant to services your physician rendered that day. The nine choices for the fourth digit of 250.xx are as follows:

0 - Diabetes mellitus without mention of complication

1 - ...with ketoacidosis

2 - ...with hyperosmolarity

3 - ...with other coma

4 - ...with renal manifestations

5 - ...with ophthalmic manifestations

6 - ...with neurological manifestations

7 - ...with peripheral circulatory disorders

8 - ...with other specified manifestations (e.g., hypoglycemic shock)

9 - ...with unspecified complication.

2. Identify Type for Fifth Digit

The fifth digit provides the final two pieces of information on the patient's diabetic condition: the diabetes type (I or II) and whether the patient's diabetes is controlled.

To select the proper fifth digit, you first must know what the following ICD-9 descriptor terms mean:
 

 Type I: The patient's pancreatic beta cells no longer produce insulin. People with type I diabetes must take insulin. ICD-9 descriptors also refer to type I as "juvenile type" diabetes.
 

 Type II: The patient's beta cells do not produce sufficient insulin or the beta cells have developed insulin resistance. Unlike people with type I, people with type II may or may not have to take insulin.
 

 Not stated as uncontrolled: The patient's diabetes is managed sufficiently by diet and/or insulin.
 

 Uncontrolled: A patient can have uncontrolled diabetes when the physician documents that blood sugar levels are not acceptably stable, when the patient is not in compliance with his diabetes management plan or if the patient is taking medications for another illness that interfere with diabetes management.

First, check your physician's documentation to see what type of diabetes the patient has and if the condition is controlled. Then choose from one of the following fifth digits:
 

 0 - Type II or unspecified type, not stated as uncontrolled

 1 - Type I (juvenile type), not stated as uncontrolled

 2 - Type II or unspecified type, uncontrolled

 3 - Type I (juvenile type), uncontrolled.

Example: Suppose your physician treats an uncontrolled, type II diabetic suffering from peripheral circulatory disorders. You would report 250.72 (Diabetes mellitus; diabetes with peripheral circulatory disorders; type II or unspecified type, uncontrolled).

3. Determine if Diabetes Is Primary

After you've chosen the patient's correct 250.xx code, a new question can arise: Is diabetes the primary or secondary diagnosis? Your physician could treat a patient for a problem not directly related to the diabetes, but you may still need to indicate the patient's complete medical condition with a 250.xx code.

Because every diabetes case is different, there is no hard and fast rule regarding when the diabetes should be the patient's primary or secondary diagnosis. "The nature of the presenting problem should govern the diagnosis code," advises Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, PA.

Study these three scenarios to help you determine if you should list diabetes first as the primary diagnosis:
 

 Diabetic patient with new foot ulcer: Code the foot ulcer as the primary diagnosis, and list the diabetes mellitus as the secondary diagnosis, Falbo instructs. Diabetes is secondary because it is a relevant condition that influences the patient's treatment and care, as well as the cause of the ulcer, she says.

And the patient saw the doctor specifically for the foot ulcer, not for diabetes management, points out Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions, Inc. in Brick, NJ.

Listing the appropriate 250.xx code can also help justify a higher-level E/M because the condition complicates the physician's treatment plan, and requires extra time and more complex decision-making on the part of the physician.

 Diabetic with slow-healing arm laceration: The wound is the primary diagnosis because it is the problem the physician is actively treating. You should report the diabetes as secondary because the condition is causing the wound to heal slowly, and also complicates the physician's treatment plan, says Judy Richardson, MSA, RN, CCS-P, senior consultant at Hill & Associates in Wilmington, NC.

 Diabetes management visit and physician finds diabetic ulcer: You would code the diabetes as the primary diagnosis and the wound as secondary, explains Richardson, because the diabetes is the acute condition the patient  initially presented with for treatment.

4. Mind Your Manifestations

Five diabetes code fourth digit descriptors require that you report a manifestation diagnosis code as well. Always report the manifestation code as a secondary diagnosis. And remember, not all diabetes fourth digits require a manifestation code - the code descriptor will tell you if you need one.

Here's a partial list of the diabetes codes that require a corresponding manifestation code, paired with some possible diabetic manifestations:

 250.5x  - 366.41 (Cataract; cataract associated with other disorders; diabetic cataract)
 

 250.6x - 357.2 (Inflammatory and toxic neuropathy, polyneuropathy in diabetes)
 

 250.7x - 443.81 (Other peripheral vascular diseases; other specified peripheral vascular diseases; peripheral angiopathy in diseases classified elsewhere)

Keep in mind: The ICD-9 manual does not list all possible manifestation codes that you might need to choose from when you report one of the 250.xx codes above.

You can report them all: If a patient suffers from more than one diabetic complication, you can code the multiple complications and their manifestations on a single claim, making sure to link the manifestations to the correct diabetes codes. 

For example, "if a physician is treating the patient for diabetes with renal manifestations, and the patient also has ophthalmic manifestations, report both [sets of codes] since most likely the prescription management or plan of care will need to consider these other manifestations," says Falbo.

Sequence matters: Remember to report first the particular manifestation your physician treated that day. Or, if the physician is dealing with multiple complications, code according to the order in which the physician rendered treatment. Finally, if the documentation does not indicate the treatment order, you should report the most prominent or advanced complication and corresponding manifestation first.

5. Insert V Codes for Insulin Pump

Just as fourth and fifth digits paint a more complete picture of a patient's diabetes, V codes are also important for telling the carrier the whole story. Assign V58.67 (Long term [current] use of insulin) as a secondary code for patients who take insulin on a regular basis.

V codes also come into play for diabetes patients receiving their insulin via insulin pumps. Three V codes apply to different stages of the insulin pump treatment process. When you code an E/M visit concerning an insulin pump, report the appropriate 250.xx code and one of the following insulin pump V codes as a secondary diagnosis:

 V65.46 (Encounter for insulin pump training) for when a patient is first considering an insulin pump and receives education about the device.
 

 V53.91 (Fitting and adjustment of insulin pump) for when the patient first receives the insulin pump from the physician.
 

 V45.85 (Insulin pump status) for all other follow-up visits associated with the pump.


Use ICD-9 code 996.57 (Complication due to insulin pump) to report insulin pump mechanical complications.

6. Go to 648.8x for Cases of Gestational Diabetes

One type of diabetes you won't find within the 250.xx series is gestational diabetes - a condition that only develops during pregnancy and disappears after delivery.  For this type of diabetes, use 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.

Include V58.67 if the physician is treating the gestational diabetes with insulin, says Nancy L. Reading RN, BS, CEO of Cedar Edge Medical Coding and Reimbursement in Centerfield, UT.

Distinction: For pregnant women who are diabetic (suffering from diabetes before becoming pregnant), you should assigned 648.0x (...diabetes mellitus) as the primary code, and then the appropriate 250.xx code to identify the type of diabetes, Reading advises.

Warning: You should never report 648.0x and 648.8x together, says Reading.