Diabetes Diagnoses

Medical Economics, March 16, 2007 | Go to article overview

Diabetes Diagnoses


Patients who have diabetes often have one or more complications that require your extra attention, and these added problems can have a significant effect on the E&M level you bill. Use these steps for diabetes diagnosis coding to ensure that your ICD-9-CM codes justify the services you bill.

Use the correct digits

Determine the fourth digit for 250.xx (diabetes mellitus) according to the type of diabetic complication the patient has (1 for ketoacidosis, 4 for renal conditions, 6 for neurological involvement, etc.). You should code only the complication relevant to the services you render during the visit.

The fifth digit provides the final two pieces of information on the patient's diabetic condition and its level of control. Diabetes Type I defines the disease when the patient's pancreatic beta cells no longer produce insulin; these patients take insulin. In Type II the patient's beta cells don't produce sufficient insulin or the beta cells have developed insulin resistance. Patients with Type II may or may not take insulin. When the patient's blood sugar levels aren't acceptably stable, when he's not in compliance with his diabetes management plan, or if he's taking medications for another illness that interfere with diabetes management, the disease is deemed "uncontrolled." Select the proper fifth digit based on the ICD-9-CM descriptor terms:

* Type I, not stated as uncontrolled, use fifth digit 1.

* Type I, uncontrolled, use fifth digit 3.

* Type II, not stated as uncontrolled, use fifth digit 0.

* Type II, uncontrolled, use fifth digit 2.

Is the diabetes primary?

After you've chosen the patient's correct 250.XX code, you must decide if diabetes is the primary or secondary diagnosis. You could treat a patient for 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.

There's no hard and fast rule regarding when the diabetes should be the patient's primary or secondary diagnosis. The nature of the presenting problem should govern the diagnosis code. Study these three scenarios to help you determine if you should list diabetes as the primary diagnosis:

* Diabetic patient with a new foot ulcer: Code the foot ulcer as the primary diagnosis and list the diabetes as the secondary diagnosis. It's secondary because it's a relevant condition that influences that patient's treatment and care, as well as the cause of the ulcer. And the patient saw you specifically for the ulcer, not for diabetes management. Listing the appropriate 250.xx code can also help justify a higher-level E&M service because the condition complicates your treatment plan and requires extra time and more complete decision-making.

* Diabetic with slow-healing arm laceration: The wound is the primary diagnosis because it's the problem you're actively treating. Report the diabetes as secondary because the condition is causing the wound to heal slowly and also complicates your treatment plan. …

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