Part B Insider (Multispecialty) Coding Alert

First step:  Check the physician's documentation for diagnosis cause

Remember this rule when coding diabetic manifestations: If you can’t establish a cause and effect relationship between diabetes and a manifestation, you can’t code a diabetic manifestation. Here are four more clues that will set you on the right diabetes coding course.

1. Know A Manifestation When You See One

Don’t assume that a diabetic patient’s diagnosis is a manifestation. Read the patient record carefully to see whether there is a link between the diagnosis and the diabetes.

“A cause and effect relationship between the diabetes and what may or may not be the manifestation must be determined by the physician,” says Susan Hull, MPH, RHIA, CCS, CCS-P, manager of practice resources with the American Health Information Management Association in Chicago.

Tip: Make sure to read the physician’s notes carefully. Query the physician if you suspect a cause and effect relationship but don’t see it documented in the patient record.

Example: A patient may have gastroparesis and diabetes. If the physician says that the patient has diabetic gastroparesis, then you know that there is a cause and effect relationship, which indicates that the gastroparesis is a manifestation of the diabetes. But if the physician noted only gastroparesis and diabetes, you cannot assume that there is a cause and effect relationship.

Do this: Code diabetic gastroparesis as follows:

• 250.6x (Diabetes with neurological manifestations) and
• 536.3 (Gastroparesis).

For a patient with diabetes and gastroparesis but no link between the two, you would report:

• 563.3 (Gastroparesis) and
• 250.x (Diabetes without mention of complication).

2. Diabetes Code Gets Top Billing

Always report the diabetes code first, followed by the code for the manifestation. This sequencing rule is noted in the ICD-9 CM manual whenever you reference a diabetic manifestation.

Look for: Slanted brackets in the alphabetic indexes. These brackets indicate mandatory multiple codes, which you must report in the order listed in the ICD-9 CM manual. Also watch for the note “Code first underlying disease” which reminds you to list diabetes first.

To code a manifestation of diabetes properly, first assign the appropriate code from the 250.xx category, and then follow up with the appropriate manifestation code. Codes for diabetes with manifestations include:

• 250.4x (Diabetes with renal manifestations),
• 250.5x (Diabetes with ophthalmic manifestations),
• 250.6x (Diabetes with neurological manifestations)
• 250.7x (Diabetes with peripheral circulatory disorders)
• 250.8x (Diabetes with other specified manifestations), and
• 250.9x (Diabetes with unspecified complication).

Caution: In some cases, there is one code for an established diabetic manifestation and an entirely different code when there is no cause and effect relationship between the diabetes and the additional diagnosis. Be sure to use the code that represents the diabetic manifestation, warns consultant Pat Trela, RHIA, from PaTrela Consulting in Quincy, MA.

Example: For a patient who has diabetic peripheral vascular disease, code 250.7x (Diabetes with peripheral circulatory disorders) first and then code 443.81 (Peripheral angiopathy in diseases classified elsewhere). If the patient has peripheral vascular disease and no established cause and effect relationship with diabetes, you would report only 443.9 (Peripheral vascular disease, unspecified).

3. Manage Multiple Manifestations Properly

A patient may have multiple manifestations with one diabetic complication. A patient can also have several diabetic complications and corresponding manifestations. “The important thing is to always select the right code for the complications(s) and code as many manifestations as there are,” says Hull.

Example 1: For a patient with diabetes with neurological manifestations that include gastroparesis and peripheral neuropathy, code as follows:

• 250.6x (Diabetes with neurological manifestations),
• 536.3 (Gastroparesis), and
• 337.1 (Peripheral autonomic neuropathy in disorders classified elsewhere).

Example 2: For a patient with diabetic polyneuropathy and gangrene, code as follows:

• 250.6x (Diabetes with neurological manifestations),
• 357.2 (Polyneuropathy in diabetes),
• 250.7x (Diabetes with peripheral circulatory disorders), and
• 785.4 (Gangrene).

4. Know When Diabetes Is Primary

You should always list a diabetes code before the corresponding manifestation code, but that doesn’t mean diabetes is always the primary diagnosis. Diabetes is only primary if it’s the main reason the physician is treating the patient.

Scenario: A patient who has stable type II diabetes without complications (250.00) is being treated for an acute episode of pneumonia and dehydrations with antibiotics, fluids and steroids.

The infectious process and the use of the steroids have elevated the patient’s blood sugars above normal values. Unless the physician documents uncontrolled diabetes, you can’t code it as such. But the fact that you have the doctor’s orders for sliding scale regular insulin coverage with fingersticks before meals and at bedtime shows concerns for the diabetes. The primary diagnosis is pneumonia because that is the reason the patient is being treated, while the diabetes is secondary. Here’s how you should code this situation:

• 486 (Pneumonia, organism specified), unless you know the causative organism or unless the pneumonia is due to aspiration, and

• 250.00 (Type II diabetes mellitus without mention of complication, not states as uncontrolled).