Keep in mind these coding tips to improve medical record documentation

This article is part of a series on coding tips.

Last month’s article in this series focused on accurate documentation for diabetes and its manifestations. This month, we’re taking a look at the correct coding for renal, ophthalmic, neurological and peripheral circulatory manifestations of this complex condition.

Common documentation and coding challenges for diabetic 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 a primary diabetes code.

• The wrong manifestation code is reported for the condition.

Selection of manifestation codes
A common coding error for diabetes is the selection of the wrong manifestation code. In some cases, the code reported when the condition is a manifestation of diabetes isn’t the same code that’s reported when the condition exists independently.

This is an easy distinction for a coder to make by referencing the alphabetic index or tabular of ICD-9-CM, but providers who select their own codes through search engines in an electronic medical record will often select the wrong code for the manifestation. 

For example, idiopathic progressive polyneuropathy is coded as 356.4 if it’s the patient’s primary condition. However, if the patient has polyneuropathy due to diabetes, it’s coded as 357.2 (polyneuropathy in diabetes). 

Tips for diabetes with renal manifestations – 250.4x

Code 250.4x, followed by the appropriate manifestation code for diabetes with renal manifestations:

• When documentation states diabetic nephropathy or diabetic nephritis, not specified as acute or chronic, code 583.81 as the manifestation. 
• When reporting codes for chronic kidney disease (585.1-585.5), the specific stage of the disease must be stated in the documentation. CKD stages cannot be coded based on the glomerular filtration rate. 
• Code 581.81 if documentation indicates intercapillary glomerulosclerosis, also known as Kimmelstiel-Wilson disease. The same code is also used for nephrosis or nephrotic syndrome, which refers to a degenerative disease of the renal tubules. 
• If documentation indicates both a stage of CKD and end-stage renal disease, report code 585.6 only.
  

Tips for diabetes with ophthalmic manifestations – 250.5x

Code 250.5x, followed by the appropriate manifestation code for diabetes with ophthalmic manifestations:

• The code for macular or retinal edema, 362.07, cannot be used without one of the codes for diabetic retinopathy. Diabetic macular edema is only present with diabetic retinopathy.
• Use caution when selecting a cataract code. There’s a difference between a diabetic cataract (366.41) and a senile cataract (366.10-366.19). Only a diabetic or “snowflake” cataract can be classified as a manifestation of diabetes.

Tips for diabetes with neurological manifestations – 250.6x

Code 250.6x, followed by the appropriate manifestation code for diabetes with neurological manifestations:

• Documentation specifying “diabetic peripheral neuropathy” or “loss of protective sensation” due to diabetes should be assigned to polyneuropathy, code 357.2. This is the most common form of diabetic neuropathy, affecting the feet, legs and sometimes the hands and arms.
• Autonomic neuropathy affects the autonomic nervous system, which controls the heart, bladder, lungs, stomach, intestines, sex organs and eyes. Many conditions are attributed to autonomic neuropathy and should be reported with 337.1, and the code for the autonomic manifestation, if specified:
• Gastroparesis and gastroparalysis: 536.3
• Orthostatic hypotension: 458.0.
• Report 353.5 for diabetic amyotrophy, also known as radiculoplexus neuropathy, femoral neuropathy or proximal neuropathy. This condition affects nerves in the thighs, hips, buttocks or legs.
• Report the appropriate code from 354.0 – 355.9 for mononeuropathy, also known as focal neuropathy. This condition involves damage to a specific nerve in the face, torso or leg. It can also occur when a nerve is compressed, like in the case of carpal tunnel syndrome.
• Code 713.5 for neurogenic arthropathy (charcot joint), which occurs when a joint deteriorates because of nerve damage, usually in the ankle or foot. 
• For ulcers caused by diabetic neuropathy, report the appropriate manifestation code, followed by a code from 707.1 – 707.19 for the ulcer. If gangrene is present, also code 785.4. 

Tips for diabetes with peripheral circulatory disorders – 250.7x

Code 250.7x, followed by the appropriate manifestation code for diabetes with peripheral circulatory disorders:

• Peripheral vascular disease or peripheral arterial disease caused by diabetes is coded as 443.81 (peripheral angiopathy in diseases classified elsewhere).
• Ulcers caused by peripheral vascular disease are reported with 443.81, and a code from 707.1 – 707.19 for the ulcer. If gangrene is present, also code 785.4. 
• If documentation states atherosclerosis of the extremities due to diabetes, use code 440.2x.

Tips for diabetes with other specified manifestations – 250.8x
Code 250.8x, followed by the appropriate manifestation code for diabetes with other specified manifestations:

• Diabetic hypoglycemia or hypoglycemic shock is reported with 250.8x. No manifestation code is required for this condition.
• Code 250.8x if an ulcer is specified as diabetic, but documentation does not specify if it’s due to peripheral vascular disease or polyneuropathy. Use an additional code from 707.10-707.19, 707.8, or 707.9 to identify the ulcer.
• For diabetic osteomyelitis, report 731.8 and a code from category 730.

Other tips for diabetes and ulcers

• If the ulcer is caused by a superimposed infection, it shouldn’t be coded as a manifestation of diabetes. Not all ulcers in diabetic patients are related to the condition. 
• Pressure ulcers, also known as decubitus ulcers, shouldn’t be coded as a manifestation of diabetes.

These manifestation coding tips should also be followed when coding series 249 for secondary diabetes. Remember to code for the underlying disease or condition first, followed by a code from series 249.

Be sure to check out next month’s edition of The Record, which will include an article about coding tips for chronic obstructive pulmonary disease.

Nothing in this article is intended to provide legal advice and, as such, it remains the responsibility of providers to ensure that all coding is done in accordance with applicable state and federal laws and regulations.