Pediatric Coding Alert

Hint: Report only diabetic complications related to current episode of care.

Veteran coders may recall with nostalgia the days when all pediatric diabetes patients were assigned the same diagnosis code--but those days are over.

Not only has ICD-9 expanded the diabetes code set over the years to enhance specificity, but pediatricians are also seeing patients with more complex cases. While in the past it was rare to see pediatric patients with Type II diabetes, now it's becoming commonplace. In addition, pediatricians often treat diabetic manifestations. Use these three steps for definitive diabetes diagnosis coding to ensure that your ICD-9 codes justify the services you bill.

1. Select Fourth Digit First

You must determine the fourth digit for 250.xx (Diabetes mellitus) according to the type of diabetic complication the patient has, if any. Diabetes patients may have more than one complication. If this is the case, you should code only the complication relevant to services the physician renders that day.

For example: A pediatric patient presents with diabetic hypoglycemia. In this situation, you should report 250.8 (Diabetes with other specified manifestations) as your first four digits.

If, however, the patient presents with diabetes without any complications, your first four digits will be 250.0 (Diabetes mellitus without mention of 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 it is controlled.

To select the proper fifth digit, you must first 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 "juveniletype" diabetes.

Type II: The patient's beta cells do not produce sufficient insulin, or the beta cells have developed insulin resistance. People with type II 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 the physician's documentation to see what type of diabetes the patient has and whether the condition is controlled. Then choose 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.

Your list of frequently used diagnoses will include a lot of 250.01s and 250.00s. The majority of patients your practice sees will fall into one of these two categories.

Selecting between Type I and Type II: Just because Type I diabetes has the phrase "juvenile type" in parentheses following the descriptor, don't assume that all pediatric patients have Type I diabetes. It is becoming increasingly common for pediatricians to treat Type II diabetes developed in childhood or adolescence.

Helpful in determining whether a patient has Type I or Type II diabetes is the results of a C-peptide assay, which measures insulin production and can indicate which type of diabetes is present. These test results may be important as you select your fifth digit.

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?

In most cases, you'll treat 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.

Example: A pediatric diabetic patient presents with a urinary tract infection (599.0). Code the infection as the primary diagnosis, and list the diabetes mellitus as the secondary diagnosis (this would be 250.81). Diabetes is secondary because it is a relevant condition that influences the patient's treatment and care, but did not lead to the infection.

If, however, the patient presents with a diabetic condition or with a condition due to diabetes (such as diabetic ketoacidosis), the diabetes diagnosis code must be sequenced as the principal diagnosis (this would be 250.13), followed by the code for the specific condition (such as infectious gastroenteritis, 009.1).