Vol. 14 •Issue 19 • Page 14
Test Preparation Must Include Brushing Up On Guidelines for Coding Diabetes Mellitus
Diabetes mellitus is a condition that results when the body is unable to produce enough insulin or properly use the insulin that it does produce. The disease of diabetes is present in a significant number of patients and consumes more than $100 million in health care resources in the United States. Therefore it is important that the guidelines for coding diabetes mellitus are und1erstood. Correct coding of diabetes is critical in determining the correct reimbursement for encounters related to this disease and for tracking health care services provided for this population of patients. An incorrect code may result in a medical necessity denial for outpatient service or may result in an incorrect DRG assignment.
Before assigning a code for diabetes there are three questions that must be answered:
1. What type of diabetes does the patient have?
2. Does the documentation indicate that the diabetes is uncontrolled?
3. Are there manifestations or complications and what are they?
The ICD-9-CM code for diabetes is assigned to category 250 Diabetes Mellitus. The fourth digit is determined by the presence of manifestations or complications identified as due to diabetes. The type of diabetes and whether it is controlled or not controlled determines the fifth digit.
Types of Diabetes
There are two types of diabetes mellitus: Type I and Type II. Type I is characterized by the body’s inability to produce insulin and requires insulin injections to sustain life. These patients are truly insulin dependent. In Type II diabetes insulin is produced, but it may not be enough to control blood glucose levels or the body is unable to effectively utilize the insulin that it does produce. Type II diabetics may require insulin to help control their blood sugars but they are not truly insulin dependent. Type II represents more than 90 percent of all diabetics.
There has been significant confusion on how to choose the correct type of diabetes. Terms like IDDM, NIDDM, adult onset and juvenile are often documented in the medical record but the guidelines for coding using these terms are contradictory and have been open for interpretation. Therefore, effective Oct. 1, 2004, the code descriptions for the fifth-digit selection of category 250 Diabetes Mellitus have been revised as follows. Notice that the revisions remove the terms IDDM type, adult onset type, and non-insulin dependent type from the code descriptions.
•0: Type II or unspecified type, not stated as uncontrolled. Fifth-digit 0 is for use for Type II patients, even if the patient requires insulin
•1: Type I [juvenile type], not stated as uncontrolled
•2: Type II or unspecified type, uncontrolled. Fifth-digit 2 is for use for Type II patients, even if the patient requires insulin
•3: Type I [juvenile type], uncontrolled
When determining the type of diabetes, it is important that coders not take into consideration the patient’s age when diabetes was diagnosed or the fact that the patient receives insulin. As mentioned above, the determining factor in the assignment of the fifth digit for diabetes mellitus is whether the patient is Type I or Type II. If documentation is unclear, then the physician must be queried to determine the type. If the type is still unknown, the fifth-digit of 0 or 2 is assigned.
Additional guidelines to assist in identifying the type of diabetes are expected to be published in future issues of Coding Clinic. Until these guidelines are distributed, Type I or Type II must be documented to determine the correct code assignment.
Controlled vs. Uncontrolled
Once the type of diabetes is identified, it must be determined if the diabetes is controlled or uncontrolled to assign the appropriate fifth-digit. Uncontrolled diabetes is a nonspecific term indicating that the patient’s blood sugar level is not within acceptable levels based on the patient’s current treatment regimen. There can be a variety of reasons for this including noncompliance, dietary indiscretion and intercurrent illness. Depending on the type of diabetes, code 250.x2 or 250.x3 is used to code uncontrolled diabetes. Uncontrolled diabetes should not be coded unless the physician’s documentation indicates that the diabetes is uncontrolled or out of control. You cannot assume that poorly controlled diabetes means uncontrolled without additional documentation from the physician. If the documentation is unclear, query the physician as to whether or not the patient’s diabetes is uncontrolled.
Manifestations and Complications
To assign the fourth digit, coders must determine if there are any complications or manifestations of the diabetes. If none are present then code 250.0x Diabetes Mellitus without Mention of Complication, is assigned. If present, complications will generally fall into two categories:
•Acute metabolic complications (250.1x-250.3x)
•Chronic complications (250.4x-250.8x)
Acute metabolic complications such as ketoacidosis, hyperosmolality with or without coma or other coma will be assigned to one of the following codes:
•250.1X, Diabetes with Ketoacidosis
•250.2X, Diabetes with Hyperosmolality
•250.3X, Diabetes with Other Coma
Because the acute metabolic complication is part of the diabetes itself, an additional code is not required.
Code 250.9X, Diabetes with Unspecified Complications includes those metabolic complications of diabetes that cannot be assigned elsewhere.
Chronic Diabetic Complications
Diabetic patients are susceptible to chronic conditions and complications that affect a number of body systems but primarily the renal, vascular and nervous systems. Chronic or long-standing conditions or manifestations are coded first to the appropriate diabetic code, 250.4X-250.8X, with an additional code to identify the specific complicating condition or manifestation. Dia-betic patients will often have more than one complication present at the same time. In these instances more than one code from subcategories 250.4x-250.8x should be used along with a manifestation code for each.
It is important to remember that conditions listed with a diagnosis of diabetes or in a diabetic patient are not necessarily complications of the diabetes. There must be documentation that indicates a cause-and-effect relationship between the diabetes and the condition before it can be coded as a diabetic condition. Documentation that indicates a cause and effect relationship includes “due to,” “caused by,” and “secondary to.” When there is no documentation indicating that the condition is related to the diabetes, code the condition first and the diabetes as an additional code.
Gangrene and osteomyelitis are exceptions to the above rule. There is an assumed relationship between these conditions and diabetes unless there is documentation that specifically indicates that the osteomyelitis/gangrene is due to something other than diabetes.
Diabetic patients who undergo pancreatic transplants often continue to experience complications or manifestations of diabetes such as diabetic retinopathy or peripheral neuropathy due to diabetes. In these instances the appropriate diabetic code, 250.4X-250.8X, should be assigned along with an additional code to identify the specific complicating condition. Even in the absence of a diabetic complication, diabetes mellitus may still be present following pancreatic transplant. Diabetes should be coded when the physician documents this condition in the medical record.
250.4X, Diabetes with Renal Manifestations
Chronic renal failure, nephrosis and nephritis are common diabetic complications. To code diabetic nephropathy assign 250.4X and 583.81, Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere. Diabetic nephrosis and diabetic nephrotic syndrome are coded to 250.4X and 581.81, Nephrotic syndrome in diseases classified elsewhere.
250.5X, Diabetes with Opthalmic Manifestations
Diabetic retinopathy is often seen in diabetic patients. Patients who have been diabetic for a long time and/or those who have poor control of blood sugar levels are more likely to develop diabetic retinopathy. Diabetic retinopathy is coded with 250.5X and 362.0X depending on the type of retinopathy.
250.6X, Diabetes with Neurological manifestations
Peripheral, cranial and autonomic neuropathies are very common chronic manifestations of diabetes. For example, the codes for peripheral (or cranial) neuropathy are 250.6X and 357.2, Polyneuropathy in diabetes. For autonomic neuropathy assign 250.6X and 337.1, Peripheral autonomic neuropathy in disorders classified elsewhere.
250.7X, Diabetes with peripheral circulatory disorders
Peripheral vascular disease is also a common diabetic complication. Peripheral vascular disease is coded to 250.7X and 443.81, Peripheral angiopathy in diseases classified elsewhere. Diabetic arteriosclerosis with gangrene is coded to 250.7X, 440.2, Arteriosclerosis of arteries of the extremities and 785.4, Gangrene.
It is important to note that diabetes with ischemic heart disease (410-414) and cerebrovascular disease (430-438) are coded as separate entities and are not included in code 250.7X.
Diabetes with Other Manifestations
Diabetic patients often develop foot ulcers that may be due to diabetic neuropathy or peripheral vascular disease. In these instances assign codes 250.6x or 250.7x as appropriate and 707.1x ulcer of lower limbs, except decubitus. If the cause of the diabetic ulcer is not known assign code 250.8x, Diabetes with other specified manifestation. Do realize that all ulcers in diabetic patients are not necessarily diabetic ulcers. If documentation in the medical record is not clear or there is a question as to the relationship between the ulcer and the diabetes, query the physician.
When coding diabetes with osteomyelitis assign codes 250.8x, 731.8, Other bone involvement in diseases classified elsewhere and 730.0x, Acute osteomyelitis. As stated previously ICD-9-CM assumes a relationship between diabetes and osteomyelitis unless the physician indicates that the acute osteomyelitis is totally unrelated to the diabetes.
The term diabetic triopathy refers to the presence of nephropathy, neuropathy and retinopathy in a diabetic patient. These microvascular complications occur in the major tissues affected by diabetes: the retina, the kidney and the nerves due to problems with blood flow down to the capillary level. Because there is not a single mani-festation code that encompasses diabetic triopathy, each condition must be coded separately with the appropriate diabetes codes listed first. The sequencing of the codes will depend on the circumstances of the encounter.
•.ICD-9-CM Official Guidelines for Coding and Reporting: Section I.A.6 Etiology/manifestation convention
•ICD-9-CM Coding Handbook.
4th Quarter 1993, pages 19-21
3rd Quarter 1991, pages 3-12
2nd Quarter 1997, page 14
2nd Quarter 2001, page 16
2nd Quarter 2002, page 13
1st Quarter 2004, pages 14-15
Utilize the new fifth-digit definitions for category 250 Diabetes Mellitus codes when choosing your answers.
1. A patient with diabetic neuropathy is admitted to the hospital because of uncontrolled diabetes. Which of the following is the correct diagnosis code assignment?
a. 250.92, 250.62, 357.2
b. 250.62, 250.92, 357.2
c. 250.93, 250.63, 357.2
d. 250.62, 357.2
e. 250.63, 357.2
2. A patient with Type II diabetes mellitus with diabetic peripheral neuropathy fails to adjust his insulin drug dosage and participates in strenuous activity. The patient is admitted with a blood sugar of 30. The discharge diagnosis is hypoglycemia. Which of the following is the correct diagnosis code assignment?
a. 250.60, 250.80, 337.1
b. 250.80, 250.60, 337.1
c. 250.62, 250.82, 337.1
d. 250.82, 250.62, 337.1
3. A patient is seen and treated for a decubitus ulcer of the heel. The physician also documents IDDM with peripheral vascular disease. Which of the following is the correct diagnosis code assignment?
a. 250.70, 707.0, 443.81
b. 250.71, 707.0, 443.81
c. 707.0, 250.70, 443.81
d. 707.0, 250.71, 443.81
4. A patient with IDDM is admitted in a hyperosmolar coma with blood sugars out of control. During the hospital stay, insulin was regulated and the coma resolved. This patient also has diabetic nephropathy with a complication of nephrotic syndrome. Which of the following is the correct diagnosis code assignment?
a. 250.23, 250.43, 581.81
b. 250.22, 250.42, 581.81
c. 250.32, 250.42, 581.81
d. 250.32, 250.43, 581.81
This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS Inc. (www.hssweb.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Answers to CCS Prep!: 1) d. Code 250.62, Diabetes with neurological manifestations, Type II or unspecified, uncontrolled, is assigned as the principal diagnosis. Code 357.2, Polyneuropathy in diabetes, is assigned as an additional diagnosis to identify the neuropathy. Code 250.9x, Diabetes with unspecified complication, would not be assigned as an additional diagnosis. Code 250.9x is never assigned with any other code from the 250.0x-250.8x series. When the specific complication is identified it would be incorrect to also assign a code stating “unspecified complication.” Code 250.92 would have been appropriate if “uncontrolled diabetes” was documented without mention of any further manifestations; 2) b. 250.80, Diabetes with other specified manifestations is assigned as the principal diagnosis. Hypoglycemia in diabetic patients is coded to other specified complications and is not identified using an additional code for the hypoglycemia. Codes 250.60, Diabetes mellitus with neurological manifestations and 337.1, peripheral autonomic neuropathy in disorders classified elsewhere are assigned as secondary diagnoses to identify the diabetic peripheral neuropathy. The fifth digit of 0 is assigned to indicate Type II diabetes, not stated as out of control. There is no documentation that the diabetes was out of control only that the patient failed to adjust his insulin in anticipation of strenuous activity and this resulted in hypoglycemia; 3) c. The decubitus ulcer code 707.0 is sequenced first. Decubitus ulcers are not considered complications of diabetes. Code also 250.70 to identify the diabetes with peripheral vascular manifestations is assigned as an additional diagnosis. The fifth digit of 0 is assigned because the type of diabetes is not identified. IDDM or insulin dependent does not necessarily mean Type I diabetes. Code 443.81, peripheral angiopathy in diseases classified elsewhere, is also assigned to identify the peripheral vascular manifestation.; 4) b. Code 250.22, Diabetes with hyperosmolality is assigned as the principal diagnosis. The code for diabetes with hyperosmolality includes the associated coma. Codes 250.42, Diabetes with Renal Manifestations and 581.81, Nephrotic syndrome in diseases classified elsewhere are assigned as additional diagnosis to identify the diabetic nephropathy with nephritic syndromes. Both diabetes codes use the fifth digit 2 because the diabetes is documented as uncontrolled but the type is not documented. IDDM or insulin dependent does not necessarily mean Type I diabetes. Type II diabetics may also be insulin dependent.