Part B Insider (Multispecialty) Coding Alert

5 tips help your diabetes diagnosis codes justify higher-level E/M services

Reporting the details of a diabetic patient's condition gets tricky when you must select the proper fourth digit for 250.xx plus the corresponding complication codes, but our experts will show you how.

You can list them all: Your practice's diabetic patients can suffer from one or multiple diabetic complications and chronic manifestations. But what some endocrinology coders don't realize is that you can report multiple complications by listing multiple 250.xx codes with the appropriate fourth digits, explains Alison Nicklas, RHIT, CCS, director of education and training for Precyse Solutions, based in King of Prussia, Pa. Listing all the patient's complications will paint a more complete picture for your payer and help to justify higher-level E/M services.

For example, if a Type II, uncontrolled diabetic patient has four chronic manifestations -- renal, ophthalmic, neurological, and circulatory -- you can actually list 250.40, 250.50, 250.60 and 250.70, along with the corresponding manifestation codes, such as 581.81 (Nephrotic syndrome) and 366.41 (Diabetic cataract).

In outpatient settings you won't always need to list all the patient's chronic manifestations. It should suffice to list just the manifestations the endocrinologist treats on a given visit. For inpatients, however, it's likely the physician is dealing with all the patient's manifestations. In this case you would list all the appropriate codes, advises Elaine Rehmer, CPC, an administrator at Cosmopolitan Diabetes Center in Columbia, Mo.

250.xx is primary: Always code the diabetes first and report the chronic manifestation code as the secondary diagnosis, says Anita Carr, CPC, business office manager and assistant practice manager for Endocrine and Diabetes Associates in Louisville, Ky.

Remember this: The physician must clearly identify the patient's complication or chronic manifestation as being caused by the diabetes. The code descriptors in the ICD-9 manual can be confusing because they use the word "with" (i.e. Diabetes with renal manifestations), leading some coders to assume there doesn't need to be a causal connection between the complication and the diabetes, Nicklas explains. Be careful not to assume anything. The documentation must define a condition as a diabetic complication or manifestation for it to be coded as such, she adds.

5 Tips Help You Beat Tricky Complications

Each time you choose a fourth digit for 250.xx you need to also select the appropriate code to identify the specific diabetic manifestation. While the ICD-9 manual lists several possible manifestation code choices below each fourth digit descriptor, it's important to realize that this is "definitely not an exhaustive list," Nicklas explains. For example, 583.81 (Nephropathy) and 581.81 (Nephrosis) are listed as possible manifestation codes below 250.4 (Diabetes with renal manifestations), but 585 (Chronic renal failure) is not listed and is also a possible renal manifestation.

Steer clear of coding pitfalls with these tips for 5 complications:

1. Ketoacidosis: Diabetes' most serious acute metabolic complication is diabetic ketoacidosis (DKA), explains Shelley Wojtasczyk, MS, FNP-C, a nurse practitioner in a family medicine clinic in Arcade, NY. An important thing to remember with acidosis is the complication is also seen in patients with "renal failure and alcoholism -both chronic and acute alcoholism," she counsels. When coding for diabetic complications, be sure the medical chart identifies the patient as having diabetic ketoacidosis.

Only one code: Don't worry about finding an additional code to identify the ketoacidosis as you would with other diabetic complications, Nicklas says. Code 250.1 specifies that the patient has diabetic ketoacidosis and "that one code tells the whole story," she explains.

2. Renal failure: Diabetic patients can suffer from nephropa-thy, which leads to kidney failure, Wojtasczyk explains. If the endocrinologist's documentation notes the patient has chronic renal failure caused by diabetic nephrot-ic syndrome, all you really need to code is 250.4x and 585 (Chronic renal failure), explains Nicklas, who presented in a March 11 audio seminar titled "Diagnosis Coding for Diabetes." However, there are many facilities that prefer to code all three conditions, so it is completely acceptable to also list 581.81 (Nephrosis), she adds.

3. Hypertension and renal failure: Adiabetic patient may present with hypertension and renal failure as a result. If this is well documented, you only need two codes, Nicklas advises. Assign one code for the diabetes with renal manifestations (250.4x) and one code for the hypertension with renal failure (403.91). No other code is required because the renal failure is included in the hypertension code, she says. It's acceptable to assign 583.81 (Nephritis and nephropathy) in addition, but remember this is optional and should be based on what your facility wants to do.

4. Cataracts: Endocrinology coders must understand that not all diabetic patients have diabetic cataracts (commonly called snowflake cataracts), Nicklas explains. "Studies have shown that most diabetics actually have the more common senile cataracts," she says. Snowflake cataracts are very rare and are almost always found in diabetic patients, Wojtasczyk adds.

In order for you to report diabetic cataracts, the physician must document the diabetes as the cause. For diabetic cataracts, use code 250.5x (Diabetes with ophthalmic manifestations) and 366.41 (Diabetic cataract). However, for a diabetic patient with mature senile cataracts, use code 250.0x (Diabetes without mention of complication) and 366.17 (Senile cataract; total or mature).

5. Gestational diabetes:

Gestational diabetes affects women during late pregnancy, Wojtasczyk explains. To report this condition, use code 648.8 (Other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth or the puerperium; abnormal glucose tolerance). No code from the 250 series is necessary.

Important: Do not use 648.8 for a patient who is diagnosed with diabetes prior to the pregnancy. For a woman who has an established diabetes diagnosis that is complicating her pregnancy, you should report 648.0 (Other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth or the puerperium; diabetes mellitus), and then 250.xx. Assign the fourth digit to the 250 code based on whether the physician documented any complications.