Coding Consult

To submit solid diabetes claims, you should know how to report a diabetic patient's complications by selecting the correct fourth digit for 250.xx, plus the corresponding complication codes.

Your diabetic patients can have one or more complications of the disease, both acute and chronic, so report multiple complications by listing multiple 250.xx codes with the appropriate fourth digits.

For example, if a Type II, uncontrolled diabetic has four chronic manifestations—renal, ophthalmic, neurological, and circulatory, for instance—list 250.42, 250.52, 250.62, and 250.72, along with the corresponding manifestation codes, such as 581.81 (nephrotic syndrome) and 366.41 (diabetic cataract).

Code 250.xx should always be the primary diagnosis. Always code it first with the chronic manifestation code as the secondary diagnosis. In outpatient settings, you seldom need to list all the patient's chronic manifestations. Instead, list those that you treat on a given visit.

"With" in descriptors can be confusing

The code descriptors in the ICD-9-CM manual can be confusing because they use the word "with" (for example, 250.4, diabetes with renal manifestations), leading one to assume that there doesn't need to be a causal connection between the complication and the diabetes. But you must clearly identify that the diabetes has caused a patient's complication or chronic manifestation. Your documentation must define a condition as a diabetic complication or manifestation for it to be coded as such.

Although the ICD-9-CM manual lists several possible manifestation code choices below each fourth-digit descriptor, this is definitely not an exhaustive list. For instance, the manual lists 583.81 (nephropathy NOS) and 581.81 (nephritis) as possible manifestation codes below 250.4x (diabetes with renal manifestations). But the manual doesn't list 585 (chronic renal failure), even though this code is a possible renal manifestation.

  Avoid coding pitfalls with these tips for five common diabetes complications:

Ketoacidosis. The most serious acute metabolic complication of Type I diabetes, ketoacidosis, also occurs in patients with chronic and acute alcoholism. So, when coding for diabetic complications, be sure the medical chart states clearly that diabetes is the cause. Don't worry about finding an additional code to identify the ketoacidosis as you would with other diabetic complications, says Alison Nicklas, director of education and training for Precyse Solutions in King of Prussia, PA. Code 250.1x specifies that the patient has diabetic ketoacidosis, and "that one code tells the whole story."

Renal failure. If your documentation indicates that the patient has chronic renal failure caused by diabetic nephrotic syndrome, all you really need to code is 250.4x and 585 (chronic renal failure), says Nicklas. However, if you prefer to code all three conditions, you can also list 581.81 (nephritic syndrome), she adds.

Hypertension and renal failure. If these conditions are well documented, you only need two codes, Nicklas says. Assign one code for the diabetes with renal manifestations (250.4x) and one code for the hypertension with renal failure (403.91). You don't have to list any other code, because the hypertension code includes renal failure, she says. You can assign 583.81 (nephritis and nephropathy) in addition, but that's optional.

Cataracts. Snowflake cataracts are rare, but when they do occur, they occur in diabetic patients. To report diabetic cataracts, document the diabetes as the cause: Use 250.5x (diabetes with ophthalmic manifestations) and 366.41 (diabetic cataract). However, for a diabetic patient with mature senile cataracts, use 250.0x (diabetes mellitus without mention of complication) and 366.17 (senile cataract; total or mature cataract).

Gestational diabetes. To report this condition of late pregnancy, use 648.8x (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. Don't use 648.8x for a patient diagnosed with diabetes prior to the pregnancy.

For a woman who has an established diabetes diagnosis that is complicating her pregnancy, you should report 648.0x (other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth or the puerperium; diabetes mellitus), and then 250.xx.

A new V code tracks insulin use

To help you accurately report insulin use, you can use a new ICD-9-CM code, V58.67 (long-term [current] use of insulin), beginning on October 1.

You may list V58.67 for patients who routinely take insulin, says Beth Fisher, medical systems specialist with the National Center for Health Statistics in Hyattsville, MD.

According to the ICD-9-CM Official Guidelines For Coding And Reporting, Section I.C18.D.3 (Categories of V Codes), the use of codes in subcategory V58.6 "indicates a patient's continuous use of a prescribed drug (including such things as aspirin therapy) for the long-term treatment of a condition or for prophylactic use. It is not for use for patients who have addictions to drugs." You can assign V58.67 for patients who are regularly taking insulin. You may also use the code for a gestational diabetes (648.8x) patient being treated with insulin.

Although V58.67 may be used as either a first-listed or secondary code, typically, it will be used as a secondary code. As such, you'll likely report V58.67 with the category 250 codes (diabetes mellitus) that have the following fifth digits:

• 0—Type II or unspecified type, not stated as uncontrolled.

• 2—Type II or unspecified type, uncontrolled.

For example, suppose you diagnose a patient with 250.12 (diabetes with ketoacidosis; Type II or unspecified type, uncontrolled), and the patient is taking insulin. In that case, you may be able to list V58.67 as a secondary diagnosis code.

"Code 250.12 may kick back because 97 percent of the time, diabetic ketoacidosis occurs in Type I diabetics, not Type 2 diabetics," says Shelley Wojtaszczyk, a family practice NP in Arcade, NY. "If you indicate that the patient you're treating for diabetic ketoacidosis is Type II, a query will be sent out to verify."

This information provided by The Coding Institute. For a free sample issue or information on how to subscribe to any of 29 specialty-specific coding newsletters, please contact The Coding Institute, 2272 Airport Road South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592; or visit www.codinginstitute.com.

Coding Consult: Diabetes care.

Medical Economics

Sep. 3, 2004;81:14.