Vol. 12 Issue 21
Dealing with Diabetes Coding Dilemmas
By now, the September CCS/CCS-P exams have come and gone. I hope that those of you who took the exams were successful! We are ready to prepare for the upcoming exams in 2003. We will update you on future dates and/or Web access to exams in a future column. In this issue, we are going to concentrate on diabetes coding issues. This can be troublesome for both the inpatient and outpatient coders, regardless of setting. Physician documentation has a lot to do with the difficulty in the coding of this diagnosis. We will start with some important concepts, Coding Clinic direction and will then provide a quiz to test these concepts. Due to limits on space, only the codes are presented. Please refer to your ICD-9-CM code book for descriptions.
1.The Official Coding Guidelines do not address diabetes specifically, although there are many Coding Clinic issues addressing diabetes coding in both the inpatient and outpatient settings. As with all code assignments, both physician documentation AND clinical documentation, such as treatments, symptoms or ancillary report findings, should be in the record before a code is assigned. Coders must not assume diagnoses from clinical information without first querying the physician for documentation to support the code.
2. Diabetes mellitus is a chronic disorder of impaired carbohydrate, protein and fat metabolism. It is caused by either a reduction in the biologic effectiveness of secreted insulin, or a distinct decrease in the amount of insulin that can be secreted by the pancreas. Laboratory findings that may confirm diabetes include elevated blood sugar after a glucose tolerance test: 160 mg/100 ml blood, one hour after a meal; 120 mg/100 ml blood, two hours after a meal (normal is 115-130 mg/100 ml blood one hour after meal). Other findings include glycosuria in a urine specimen, increased thirst, dehydration, weight loss, weakness and excessive hunger. An abnormal glucose tolerance test is not in and of itself diabetes, and should NOT be coded to the 250 category. Rather assign code 790.2, Abnormal glucose tolerance test.
3. Turn to the tabular listing of 250.XX. You will see that there are several fourth digit subdivisions for various complications and manifestations of diabetes. For example, diabetes with neurological manifestations is assigned to category 250.6X with another code for the specific manifestation to be listed second. To assign these codes, documentation in the health record must support this causal relationship. Coders must not assume that because they saw "peripheral neuropathy" in one part of the record, and "diabetes mellitus" in another section, that they can code the combination code of 250.6X and 357.2. Rather, you must code both of the conditions as if they are unrelated, 250.00, Diabetes and 356.9, Peripheral neuropathy. The physician would need to be queried for supportive documentation within the record to assign the combination code. If the patient has more than one complication of diabetes documented, more than one combination code can be assigned to fully describe the complications. Be sure to follow the "manifestation" rule and assign the category code 250 first, followed by the manifestation code.
4. Fifth digits in diabetes coding identify whether or not the diabetes is:
0 Type II [non-insulin dependent] [NIDDM] [adult-onset type] or unspecified type not stated as uncontrolled
Type II diabetes is the more common form of diabetes mellitus, affecting up to 90 percent of the diabetic population. It is common in older adults but can occur in teenagers and young adults. Risk factors are obesity and heredity. Recently, it has been reported in the news that many children are being diagnosed with Type II diabetes. Type II diabetes is also known as "maturity onset," "adult onset," "maturity onset of the young, MODY," or "ketosis resistant." Many physicians will call Type II or non-insulin dependent diabetes "insulin requiring" or even "insulin dependent" if the patient is temporarily on insulin. The coder needs to be wary of this situation. Administration of insulin does not imply insulin dependence. The fifth digit should be determined by the Type (I or II) and NOT by whether or not the patient is on insulin. At times, Type II diabetic patients may be on insulin temporarily, but are NOT Type I diabetics. When in doubt, always query the physician for clarification and provide documentation education.
Type II diabetics make some insulin, but may need supplemental insulin to correct symptoms or persistent hyperglycemia.
1. Type I [Insulin dependent type] [IDDM] [juvenile type] not stated as uncontrolled
Type I diabetes occurs when there is an absolute lack of insulin production. This happens most often in children and young adults, although Type I diabetes can develop at any age. The cause is unknown. Most patients must be on insulin the rest of their lives. Type I diabetics require insulin to sustain life. Occasionally, patients may be on what is called a "honeymoon" period in which insulin is not required. This does not change the fact that the patient is Type I diabetic and should be coded as such.
2. Type II [non-insulin dependent] [NIDDM] [adult-onset type] or unspecified type, uncontrolled
3. Type I [Insulin dependent type] [IDDM] [juvenile type], uncontrolled
Uncontrolled diabetes must be documented by the physician within the record as either "uncontrolled" or "out of control." The words "poorly controlled" or "poor control" are not enough alone to substantiate the fifth digit of "uncontrolled." In addition, coders should never assume uncontrolled diabetes based on glucose levels, however the physician can be queried to add the documentation if it is suspected to be the case.
For an excellent clarification of insulin dependent diabetes, see CC 2Q 1997 p. 14 and CC 3Q 1991 p. 4.
5. Secondary diabetes, coded to category 251 occurs as the result of therapy such as the surgical removal of the pancreas or the use of certain medications. Hemochroma-tosis, drug use and pancreatitis are frequent causes.
6. Per Coding Clinic 1992 Second Quarter pp. 16-17, diabetes mellitus listed in the "history" section of the medical record can be coded without further physician documentation other than the final face sheet. This is one of four diagnoses that CC addresses in this manner. The others are COPD, hypertension and Parkinson's disease. CC feels that these are chronic conditions that affect the patient for the rest of his/her life.
7. Acute metabolic complications sometimes affect diabetes patients. They include ketoacidosis (250.1X) in which ketones appear in the urine and the patient has glycosuria, and hyperglycemia with acidosis (low arterial blood pH); hyperosmolar coma (250.2X), in which there is dehydration and hyperosmolarity (in-crease in the concentration of the blood), which means that there is marked hyperglycemia (over 800 mg/dL) causing osmotic shifts in water in the brain cells that can result in coma. Ketosis does not result, hence the name "nonketotic hyperglycemia"; and other coma (250.3X).
8. Pregnancy patients also can develop a condition called gestational diabetes. It is abnormal glucose tolerance occurring in patients who do not have diabetes. Technically, it is not true diabetes but is due to hormonal and metabolic changes brought on by pregnancy. For gestational diabetes, see code 648.8X for this condition. Patients with pre-existing diabetes who become pregnant are classified to code 648.0X with code 250.XX as a secondary code. It is appropriate to assign 648.0X as diabetes inevitably affects or aggravates the pregnancy in some way, and is keeping with obstetrical coding directives.
9. Hypoglycemia (low blood sugar) can manifest itself in both diabetic and nondiabetic pa-tients. If the diabetic experiences hypoglycemia, the coder must look for the cause as this will make a difference in code assignment. For example, for hypoglycemia in a diabetic pa-tient without cause, 250.80 is assigned. If due to insulin or other diabetic drug in a diabetic patient, one must determine if the correct or incorrect dosage was taken in order to assign the codes.
10. For neonatal diabetes mellitus (775.1), the coder must be sure that this or hyperglycemia of newborn (775.6) or syndrome of 'infant of diabetic mother' (775.0) is documented well in the record. Do not assume the code based on glucose readings.
11. For diabetic ulcers, the coder must determine if the physician has documented the diabetic condition related, such as diabetic neuropathy (250.6X) or diabetic peripheral vascular disease (250.7X). If a cause is not listed for the diabetic ulcers, the coder is to use 250.8X and 707.XX and determine the type of diabetes and location of the ulcer for fourth and fifth digit assignment.
Now, answer the follow- ing questions. Research the Coding Clinic if applicable, after answering from memory. Due to limits on space, only the codes are presented. Please refer to you ICD-9-CM code book for descriptions.
A) A patient is status post pancreas transplant. He has Type I diabetic nephropathy. The patient does not require insulin, however the diabetic nephropathy still exists.
1. 251.2, 583.9, V42.83
2. 250.41, 583.81, V42.83
3. 583.9, V42.83
B) The patient has progressive diabetic nephropathy, on insulin with hypertensive renal disease and renal failure.
1. 250.41, 403.91
2. 250.40, 583.81, 403.91
3. 250.40, 403.91
C) A patient with Type II diabetes with peripheral autonomic neuropathy is admitted after developing hypoglycemia. The blood sugar on admission is under 30. The patient had just completed a tag football game and forgot to adjust his hypoglycemic drug.
1. 250.80, 250.60, 337.1
2. 250.62, 337.1
3. 250.80, 250.60, 357.1
D) A patient with Type II diabetic retinopathy has accidentally taken an overdose of insulin and is in hypoglycemic shock.
1.250.80, E858.0, 250.50, 362.01
2.962.3, 250.80, E858.0, 250.50, 362.01
3.962.3, 250.52, 362.01, E858.0
E) A pregnancy patient is placed on a diabetic diet as a result of an abnormal glucose tolerance test. She is previously nondiabetic and is antepartum.
1. 648.03, 250.00
2. 648.03, 790.2
F) A patient has uncontrolled Type II diabetes mellitus, requiring insulin.
G) Poorly controlled is considered "uncontrolled diabetes mellitus" for coding purposes.
Patricia Maccariella-Hafey is director of education for Health Information Associates Inc., a company specializing in provid-ing coding compliance review services, education and contract coding for hospitals. The corporate office is headquartered in Pawley's Island, SC.
Coding Clinic is published quarterly by the American Hospital Association
"CPT only© 2001 American Medical Association. All Rights Reserved."
A) 2 (250.41, 583.81, V42.83) See CC 2001 2Q p. 16. Because the patient still has complications of the diabetes, category 250.XX must be utilized to describe the condition. The nephropathy is still affecting the patient; B) 3 (250.40, 403.91) See Faye Brown 2002 Coding Handbook, p. 95 and CC 3Q 1991 p. 8; C) 1 (250.80, 250.60, 337.1) See CC 4Q 1993 pp. 19-21; D) 2 (962.3, 250.80, E858.0, 250.50, 362.01) See CC 4Q 1993, pp. 19-21; E) 3 (648.83) See CC 3Q 1991 p. 5; F) 3 (250.02) See CC 4Q 1997 p. 33. Please note that the physician would need to specify the complication in order to use fourth digit 9. This changed when the fifth digits were developed to accommodate uncontrolled; G) 2 False. Poorly controlled is not the same as uncontrolled and must be clarified by the physician as "uncontrolled." See CC 3 Q 2002 p. 13.