Keep these coding tips in mind to improve medical record documentation

Diabetes is one of the most common and costly conditions in the U.S. This complex disease causes long-term complications affecting the renal, nervous and peripheral vascular systems, as well as the feet and eyes. According to 2012 Centers for Disease Control and Prevention statistics, diabetes continues to be the leading cause of kidney failure, nontraumatic lower-extremity amputations and blindness among adults ages 20 to 74.

It’s no surprise that documentation and coding for this complicated condition is a challenge to both health care providers and coders. Here are some tips to help improve medical record documentation for diabetes.

Common documentation and coding challenges for diabetes mellitus:

• Documentation does not support a link between diabetes to its associated complications and manifestations.
• A less specific diabetes code is reported when documentation supports a specific diabetic condition that has associated manifestations.
• The associated manifestation or “buddy” code is not reported in addition to primary diabetes code.
• Electronic medical record search engines may provide long lists of codes for diabetes, making selection of the most specific diagnosis code a challenge.
• Electronic billing systems limit number of diagnoses for patients with multiple diabetes manifestations and chronic conditions.

Diabetes has several subcategories, but the most basic subcategory is code 250.0X, for diabetes without associated manifestations. If manifestations due to diabetes are present, the appropriate subcategory should be reported. The fourth digit indicates the type of manifestation.

These codes require a fifth digit to communicate if the diabetes is Type I or Type II, and if the diabetes is controlled or uncontrolled.

Additional coding tips

• Document whether the diabetes is Type I or Type II every time you treat the patient. Documentation of insulin usage alone does not support a diagnosis of Type I diabetes. If the type of diabetes is not documented, then use the unspecified code, Type II.
• Indicate whether the diabetes is controlled or uncontrolled. Note: This can’t be inferred from lab results; it must be stated in the documentation. Per coding guidelines, “poor control” should be coded as controlled.
• Assign code V58.67 for patients that use insulin to control their diabetes. This code shouldn’t be assigned if insulin is only given temporarily to bring a patient’s blood sugar under control during an encounter.
• Assign a code from category 249.XX, secondary diabetes, when diabetes is caused by another condition or event such as cystic fibrosis, malignant neoplasm of the pancreas, pancreatectomy or adverse effect of drug or poisoning. Check ICD-9-CM guidelines for sequencing rules.
• Assign code 648.8X for gestational diabetes and report code 648.0x for obstetric patients with pre-existing diabetes. Additional codes from the 250 or 249 category should be assigned to indicate the type of diabetes.
• Many patients will have manifestations in more than one subcategory. Assign as many subcategory codes as needed to communicate the complexity of a patient’s condition.
• Report code 996.57 for underdose or overdose of insulin due to insulin pump failure. For insulin overdose, report additional code 962.3 for insulin poisoning. Next, report appropriate codes from category 250 or 249.
• Use concise words and abbreviations in EMR search engines for help in coding diabetes to the highest specificity. For example, searching for “dm with renal” or “retinopathy due to dm” instead of “diabetes mellitus” could yield a shorter and more specific list of code choices. 

Next month’s Record article on coding tips will explore coding diabetes manifestations for renal, ophthalmic, neurological and peripheral circulatory disorders