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Basic Diabetes Mellitus Pathology and Diagnosis Coding January 23, 2008 1– 3 pm MST Irene Mueller, EdD, RHIA Montana Hospital Association MT-NC Tele-Video Spring 2008 http://www.medicinenet.com/diabetes_mellitus/article.htm 1/18/2008 ILEM, EdD, RHIA Objective Assign correct ICD-9-CM codes by applying knowledge of • Basic ICD-9-CM coding conventions, • Basic ICD-9-CM coding process, and • DM Anatomy, Types, Etiology, Signs and Symptoms, Diagnosis, Acute and Chronic Complications (Manifestations), and Treatments 1/18/2008 ILEM, EdD, RHIA 1/23/08 Schedule • 1pm – 1:05 – Introductions/Overview of session • 1:05 – 1:50 pm – Diabetes Mellitus Pathology • 1:50 – 2 pm Break • 2:00 - 2:45 – DM Coding Process • 2:45- 3:00 pm – Questions 1/18/2008 ILEM, EdD, RHIA Anatomy of Diabetes • Diabetes Mellitus – – – – 1st described in 1552 BC Mellitus = Honey Urine smells sweet Food Metabolism disorder • Pancreas • Insulin hormone – Polydipsia, Polyuria, – Polyphagia • 3rd leading cause of DEATH in US (7th in 1996) • DM costs $98 BILLION annually in US 1/18/2008 ILEM, EdD, RHIA • Diabetes Insipidus – – – – 1761 –Scots carried to NA Insipidus = tasteless Urine has no odor Water Metabolism disorder • Kidney (NDI) • Pituitary (CDI) – Polydipsia, Polyuria – Much rarer • 3/100,000 Pancreas • Accessory organ of Digestive System – compound gland, has endocrine and exocrine functions • Responds to hormones – when food enters the duodenum, secretin & pancreozymin are released into the bloodstream • Functions3 – the pancreatic cells produce & release large amounts of water, bicarbonate, and digestive enzymes, which flow into the intestine (exocrines). – Islets (or islands) of Langerhans - secrete insulin and glucagon, which control sugar storage in the body. Insulin stimulates cells to remove sugar from the bloodstream and use it. Glucagon releases stored sugar and increases the blood sugar level, acting as a control mechanism whenever the body produces too much insulin. They are both secreted directly into the bloodstream (endocrines). 1/18/2008 ILEM, EdD, RHIA Pancreas Anatomy 1/18/2008 ILEM, EdD, RHIA Normal glucose control 1/18/2008 ILEM, EdD, RHIA Source: http://cascadevalley.org/resources/news/fw04-3.php DM Definition • “A group of metabolic diseases characterized by high blood sugar (glucose) levels, which result from defects in insulin secretion, or action, or both.”1 • “A chronic disorder of carbohydrate, fat, and protein metabolism caused by inadequate production of insulin by the pancreas OR faulty utilization of insulin by the cells”2 of the body. 1/18/2008 ILEM, EdD, RHIA Etiology of DM • When blood glucose rises (after eating) insulin is released • Insulin helps the cells take in glucose and convert it to energy. • Extra fat tissue can make your body resistant to the action of insulin, but exercise helps insulin work well. • DM occurs when insulin is absent, insufficient, or not used properly. 1/18/2008 ILEM, EdD, RHIA Types of DM • • • • • • • Pre-Diabetes Type 1 (about 10% of patients, 1 million in US) Type 2 (about 90% of patients) Gestational DM (GDM) Neonatal DM Secondary DM Wolfram syndrome – Autosomal recessive – Type 1 DM, DI, Optic atrophy, Deafness, Ataxia, Peripheral neuropathy 1/18/2008 ILEM, EdD, RHIA Pre-Diabetes • At least 54 million U.S. adults had prediabetes in 2002. • Most people with pre-diabetes develop Type 2 DM within 10 years – Unless lose 5 to 7 % of body weight—about 10/15 pounds for someone who weighs 200 lbs. • Pre-diabetes also creates a higher risk of heart disease. • Also documented as impaired fasting glucose (IFG = 100 – 126 mg/dl) or impaired glucose tolerance (IGT) 1/18/2008 ILEM, EdD, RHIA Risk Factors for Pre-Diabetes • Genes are partly responsible • Too much fat interferes with muscles' ability to use insulin. • Lack of exercise further reduces muscles' ability to use insulin. • Metabolic Syndrome (Insulin Resistance Syndrome, formerly Syndrome X). 1/18/2008 ILEM, EdD, RHIA Metabolic Syndrome • Insulin Resistance Syndrome, (formerly Syndrome X). Any 3 of the following – excess weight around the waist (central obesity – apple vs pear) (40+ inches - males, 35+ inches –females), – low HDL (good) cholesterol levels, (<40 mg/dL – males, <50 – females) – high levels of triglycerides (150 mg/dL +) – high blood pressure (130/85), – high fasting blood glucose (110mg/dL +) 1/18/2008 ILEM, EdD, RHIA Type 1 DM • Previously IDDM, juvenile onset, ketone-prone • Autoimmune disease – Immune system attacks beta cells in pancreas, which can’t make insulin • Causes include – Genetic (white, northern European heritage) – Viral infections (mumps, Coxsackie) – Environmental toxins? (cow’s milk/wheat in early diet?) rat poison (pyriminil) • Insulin tx required for survival 1/18/2008 ILEM, EdD, RHIA Type 1 DM • Usually occurs in young (<30), lean people • Older patients can get Type 1 – LADA – Latent Autoimmune Diabetes in Adults – Slow, progressive form of Type 1 DM 1/18/2008 ILEM, EdD, RHIA Type 2 DM • Previously - NIDDM, adult-onset DM (AODM), maturity onset, ketosis resistant, non-ketosis prone • Patients produce inadequate insulin, even if more than normal amounts, because of • Insulin resistance – Cells of body are insensitive to insulin – Especially muscle and fat cells • Steady Decline in insulin production • Glucogenesis by liver continues even though glucose is elevated • Recent studies show 15 to 45 % of all children with DM have Type 2 DM. 1/18/2008 ILEM, EdD, RHIA Risk Factors for Type 2 DM • Obesity in adults and children 1/18/2008 ILEM, EdD, RHIA – Chance of DM doubles with every 20% increase over desirable body weight. – The CDC predicts if the current rate of obesity continues, one-third of the children born in 2000 will develop DM. – up to 85% of children with Type 2 DM are obese. – Obese diabetics are also insulin resistant. Risk Factors for Type 2 DM • Obesity and insulin resistance – Research indicates – Fat cells produce fatty acids and secrete proteins that interfere with secretion and action of insulin • Obesity is most important controllable risk factor • High saturated fats, refined carbs, sedentary lifestyle 1/18/2008 ILEM, EdD, RHIA Other Risk Factors for Type 2 DM • Genetics - 45%-80% of diabetics have at least one parent with DM or a hx of DM over several generations. • Race - more common among African-Americans, Mexican-Americans, and American Indians. • Sex - Girls are nearly twice as likely as boys to develop type 2 DM. This is due to a greater insulin resistance. • Puberty - Most cases of DM in children are diagnosed between the ages of 12-16. During puberty there is increased resistance to insulin action, resulting in hyperinsulinemia. Growth hormone, which increases slightly in puberty, also has anti-insulin effects. • Age – prevalence increases with years of age • Prior gestational diabetes 1/18/2008 ILEM, EdD, RHIA Gestational DM • Pregnancy-related hormone changes can elevate glucose in genetically-predisposed • Usually resolves after birth • 25-50% of GDM women will get Type 2 DM – Require insulin during pregnancy – Remain overweight after birth • Risk factors – Family hx of DM, Obesity, 25+ yo 1/18/2008 ILEM, EdD, RHIA Neonatal DM • Rare metabolic disorder (1 of every 300,000-400,000 newborns) – Autosomal dominant genetic disorder – Within first 3 -6 months of life – Hyperglycemia combined with low insulin levels – Two groups • Transient NDM (50-60% of cases) • Permanent NDM 1/18/2008 ILEM, EdD, RHIA Secondary DM • Caused by another medical condition – Pancreas affected • Chronic pancreatitis (alcohol, other toxins) • Trauma • Surgical removal results in DM Type 1 – Hormonal disturbances • Acromegaly (excessive growth hormone) • Cushing syndrome (excessive cortisol) – Medications may cause DM/worsen control • Corticosteroids, diuretics, beta blockers, some antipsychotics (schizophrenia) • Tx of HIV/AIDS (Pentam) 1/18/2008 Tx of cancer - Asparaginase (Elspar) ILEM, EdD, •RHIA Signs and Symptoms of DM • Hyperglycemia • Cells deprived of fuel – Metabolize fats & protein – Ketone bodies as waste in blood (ketosis) • Ketonuria • Acidosis • Dehydration • N&V • Fruity breath odor • Yeast infections • Bladder & Skin infections • Coma 1/18/2008 ILEM, EdD, RHIA • • • • • • • Polyuria Polyphagia Polydipsia Weight loss Fatigue Pruritis (genital area) Blurred vision • GDM – may be symptomless! Diagnosis of DM • Patient Hx • 2 + tests on different days – Fasting Glucose • Presence in urine • Glucose – Acetone • Insulin level in blood • Eye exam to check for diabetic retinopathy 1/18/2008 ILEM, EdD, RHIA Glucose Testing • GTT (Glucose Tolerance Test) • Urine tests should be negative for presence of glucose • 2 hour postprandial – Usually after lunch – 65-139 mg/dl • Random – 200+ = DM 1/18/2008 ILEM, EdD, RHIA GTT Results Time Normal Fasting* 70-100 (preferred) mg/dl 30 minutes 100-140 1 hour 120-170 2 hours 70-120 3 hours 70-120 * Fasting = 8 hours minimum Complications vs Manifestations • Complication – “a secondary disease or condition that develops in the course of a primary disease or condition and arises either as a result of it or from independent causes” • Manifestation – “a perceptible, outward, or visible expression (as of a disease or abnormal condition)” • Source: MedlinePlus dictionary 1/18/2008 ILEM, EdD, RHIA Acute Manifestations • Diabetic ketoacidosis (DKA) – usually Type 1 DM • Hyperosmolarity – usually Type 2 • Hypoglycemia 1/18/2008 ILEM, EdD, RHIA Diabetic Ketoacidosis – Ketones in blood turn blood acidic – S&S/Finding • – N&V, abdominal pain • Glycourea, hyperglycemia, acidosis, low plasma bicarbonate – Progresses rapidly to shock, coma, death – Also caused by infection, stress, trauma, meds (corticosteroids) 1/18/2008 ILEM, EdD, RHIA Hyperosmolarity • Hyperosmolarity – the blood has a high concentration of sodium, glucose, and other molecules that normally attract water into the bloodstream. • When kidneys are conserving water (dehydration), glucose can’t leave body in urine, causing higher glucose in blood, which increases need for fluids, etc. • Causes include: infection, meds that lower glucose tolerance or increase fluid loss, inability to control glucose, stress (AMI, stroke, etc). • S&S: weakness, thirst, nausea, lethargy, confusion, convulsions, speech impairment, dysfunctional movement, loss of feeling, coma • Coma (higher risk of death than DKA) – NKHHC Nonketontic hyperglycemic hyperosmolar coma – HONK - hyperosmolar non-ketontic coma 1/18/2008 ILEM, EdD, RHIA Hypoglycemia • Abnormally low blood glucose – Too much meds/insulin (Insulin reaction) – Missed meal – Excessive exercise – CNS S&S – dizzy, confused, weak, tremors – Blood glucose = < 65 mg/dl – Can progress to coma, seizures, brain death • <40 mg/dl 1/18/2008 ILEM, EdD, RHIA Chronic Manifestations • Caused by blood vessel disease – Microvascular • Eyes, Kidneys, Nerves – Macrovascular • Heart • DM accelerates arterio/atherosclerosis • ASCVD can result in (angina, MI), stroke, claudication, BUT are NOT direct DM complications • Periodontal disease – untreated also makes control of DM more difficult 1/18/2008 ILEM, EdD, RHIA Eye Complications • • • • • • • Diabetic Retinopathy Clinically significant macula edema Vitreous hemorrhage Retinal detachment Proliferative vitreoretinopthy Neovascular glaucoma Diabetic cataract 1/18/2008 ILEM, EdD, RHIA Eye complications • • • • Diabetic Retinopathy DM for at least 5 years Small blood vessels leak protein/blood Also causes microaneurysms/neovasularization (brittle) • Progresses to retinal scarring and detachment (impaired vision, blindness) • 50% of patients have this after 10 years • 80% of patients have this after 15 years 1/18/2008 ILEM, EdD, RHIA Diabetic Retinopathy • Nonproliferative (Background) – Microaneurysms and intraretinal hemorrhages • Proliferative – More extensive hemorrhages – Neovascularization • Disease progresses from mild to moderate to severe diabetic nonproliferative, then to proliferative • Diabetic macular edema can occur at any stage 1/18/2008 ILEM, EdD, RHIA Eye • Cataracts and Glaucoma more common in Diabetics • When glucose varies, lens of eye shrinks and swells, causing blurry vision • Blood glucose should be controlled before new eye prescription 1/18/2008 ILEM, EdD, RHIA Kidney Complications • Diabetic nephropathy • 1st, small blood vessel disease causes leakage of protein in urine • 2nd, kidneys lose ability to clean/filter blood • 3rd, need for dialysis / transplant • Progression slows significantly with control of HBP and high blood glucose 1/18/2008 ILEM, EdD, RHIA Renal manifestations • Diabetic renal failure • Diabetic uremia • Diabetic glomerulonephrosis with renal failure • Diabetic nephropathy with chronic renal failure 1/18/2008 ILEM, EdD, RHIA Nerve complications • Diabetic neuropathy • Caused by ischemia • Symptoms – Numbness, burning, aching of feet/lower ext. – Lack of awareness of injuries – Combined with poor blood flow, can lead to serious infections, ulcers, gangrene 1/18/2008 ILEM, EdD, RHIA Nerve Complications • Erectile Dysfunction – Also caused by poor blood flow due to DM • Gastroparesis – Stomach and intestines nerves affected – ineffective contractions, delayed emptying of stomach – Nausea – Weight loss – Diarrhea 1/18/2008 ILEM, EdD, RHIA Prevention of Type 2 DM • Diabetes Prevention Program (DPP) • 3,234 Americans – IGT • Diet and Exercise – Lost 5-7% of weight – Exercised 30 minutes/day • Reduced risk of DM Type 2 by 58% • Metformin (Glucophage) reduced risk by 31% 1/18/2008 ILEM, EdD, RHIA Tx of DM • Intense control of blood glucose (not too low) – Decreases complications • Nephropathy • Neuropathy • Retinopathy • Macrovascular conditions – FG – 70-120 mg/dl – <160 after meals – A1c level near normal • Decrease insulin demand (diet, exercise, drugs) • Increase insulin supply (insulin, other meds) 1/18/2008 ILEM, EdD, RHIA Monitoring Glucose Levels • Patient self-testing • Hemoglobin A1c – Indicates how much glucose sticks to a red blood cell over its life of 3 months – Gives an overview of pt’s glucose control – Normal = 4 – 5.9%, <5% – Well controlled DM patients = < 6.5 – 7% • Mean blood glucose = 145 -170 – Poorly controlled DM patients = 8%+ • Mean blood glucose = 205 + 1/18/2008 ILEM, EdD, RHIA A1c • 10% decrease of microvascular disease for every 1% reduction of A1c – 37% decrease for Type 2 DM • 24% decrease of macrovascular disease for every 1% reduction of A1c • 14% decrease of MI for every 1% decrease of A1c in Type 2 DM • 21% decrease of Death for every 1% decrease ofA1c in Type 2 DM 1/18/2008 ILEM, EdD, RHIA Medications for type 1 DM • Insulin – 1977 human insulin gene cloned – Inhaled insulin Exubera – Human insulin now used Why can’t • Insulin administration insulin be • Smokers can’t use • Not sold anymore taken in – Pre-filled pens (not accepted by pill form? – Insulin pumps pts/drs • Reservoir, pump, computer – Intranasal, • About size of pager Transderm • Continuous delivery • Disappointing results • Used w/ implantable glucose – Pancreas sensors transplants • Newest sensors communicate • Whole pancreas directly w/insulin pump (1995 – 8,000) 1/18/2008 • Islet cells ILEM, EdD, RHIA Medications for type 2 DM • Meds designed to – Increase insulin output of pancreas • Sulfonyureas • Meglitinides (Prandin, Starlix) – Decrease glucose release by liver • Biguanides (metformin (Glucophage) – Increase target cells’ sensitivity to insulin • Thiazolidinediones (Rezulin – off market now) – (Actos, Avandia) – Decrease absorption of carbs (intestines) • Enzyme inhibitor (alpha glucosidase inhibitor (Precose)) – Slow emptying of stomach • Byetta 1/18/2008 ILEM, EdD, RHIA Meds for type 2 DM • New meds that affect glycemic control – – – – Pramlintide (Symlin) Used with insulin in Type 1 and 2 diabetics Exenatide (Byetta) – incretin mimetic These are injected • DPP-IV inhibitors – DPP IV is an enzyme that breaks down GLP-1 – Januvia (pill) • Combination meds – Glucovance (glyburide/metformin – Avandmet (rosiglitazone/metformin) – Metaglip (glipizide/metformin) – Pioglitazone/metformin (Actosplusmet 1/18/2008 ILEM, EdD, RHIA Tx of DM Complications • Nerve damage pain – Gabapentin (Neurontin) – Phenytoin (Dilantin) – Carbamazepine (Tegretol) – Despramine (Norpraminine) – Amitriptyline (Elavil) – Capsaicin applied topically – Pregabalin (Lyrica) – Duloxetine (Cymbalta) 1/18/2008 ILEM, EdD, RHIA Break Time Fluid Exchanges 1/18/2008 ILEM, EdD, RHIA Coding DM Diagnoses • Basic Conventions – Paired etiology/manifestation convention (dual coding) – Multiple codes – Sequencing – Index – slanted brackets – Tabular List - “with”, italics, • Official Guidelines – Section I.C.3.A.1-5 – Section I.C.11.F, G 1/18/2008 – Section I.C.18.D.3 ILEM, EdD, RHIA Pre-Diabetes • Code 790.29 1/18/2008 ILEM, EdD, RHIA DM codes • 250 4th digit – Presence of any associated manifestation • 250 5th digit – Type of DM – Whether or not “uncontrolled” • Assign as many 250 codes as needed to identify all complications/manifestations • Lists of manifestations under 250.x are NOT ONLY choices, give examples 1/18/2008 ILEM, EdD, RHIA DM documentation • Dx of diabetes w/o qualification is interpreted as DM • Physician must clearly id the DM as cause of complication or manifestation in order to use DM codes (250.xx) • Pt use of insulin does NOT indicate Type 1 • If type not specified, used Type 2, even when pt is using insulin 1/18/2008 ILEM, EdD, RHIA Adjectives in Documentation • Out of control, brittle, uncontrolled – Blood sugar is not kept within acceptable limits by tx – Indicates that DM has complications – Specified complication – code complication with 4th and 5th digit and paired code – Unspecified complication – use 4th digit .9 • Diabetic, due to DM, etc. – Establishes cause and effect – Code book sometimes assumes (Index) HOW? – If not clearly documented, query physician 1/18/2008 ILEM, EdD, RHIA Modified Documentation • “poorly controlled” or “poor control” are NOT same as “out of control” • Need to query Dr or code not stated as uncontrolled 1/18/2008 ILEM, EdD, RHIA Acute Complications of DM • Ketoacidosis (DKA) • Hyperosmolarity • Other coma 1/18/2008 ILEM, EdD, RHIA Ketoacidosis • Also occurs in alcoholism • So documentation must connect DM with ketoacidosis • 250.1x is only code required • Can occur in Type 2 DM, but 97% of time in Type 1 (so code type 1, unless Dr states 2) • Claims with 250.12 may be queried 1/18/2008 ILEM, EdD, RHIA Hyperosmolarity w or w/o Coma • 250.2x • Causes include: infection, meds that lower glucose tolerance or increase fluid loss, inability to control glucose, stress (AMI, stroke, etc). • S&S: weakness, thirst, nausea, lethargy, confusion, convulsions, speech impairment, dysfunctional movement, loss of feeling, coma 1/18/2008 ILEM, EdD, RHIA Other coma • Pts with ketoacidosis who have progressed to a comatose state • Hypoglycemic coma in a diabetic pt • Insulin coma, NOS • 250.3x 1/18/2008 ILEM, EdD, RHIA Chronic complications • DUAL coding is required • DM code sequenced 1st unless directed otherwise by Codebook • Onset can be early/late, can be in either type 1 or 2. 1/18/2008 ILEM, EdD, RHIA Vision Complications • Diabetic Retinopathy • Diabetic macular edema • Cataracts 1/18/2008 ILEM, EdD, RHIA Diabetic Retinopathy • Code for diabetic macular edema MUST BE USED with a code for diabetic retinopathy • Examples – Progress note. AODM with diabetic macular edema and nonproliferative diabetic retinopathy Codes? – Progress note. Uncontrolled adult diabetes with background diabetic retinopathy Codes? 1/18/2008 ILEM, EdD, RHIA Cataracts • Snowflake cataracts occur in DM pts, but are rare • Mature senile cataracts also occur in DM, but NOT caused by DM • Example: Snowflake cataract/diabetic cataract – 250.5x – 366.41 1/18/2008 ILEM, EdD, RHIA Renal Complications • Nephropathy – 250.4x – 583.81 • Nephritis • Nephrosis – 250.4x – 581.81 1/18/2008 ILEM, EdD, RHIA • Ch Renal Failure (new, preferred term is Ch Kidney Failure) – 585 • Ch glomerulonephritis – 250.4s, 582.8x Renal Failure • 2 codes required (250.4x and 585) • Can code intervening condition if documented and there is room for code – Shows stage of disease process • Example: CRF due to diabetic nephrotic syndrome – 250.4x – 581.81 – 585 1/18/2008 ILEM, EdD, RHIA HTN and Diabetic Renal failure • Pts w/ both DM and HTN may develop renal failure • Only 2 codes needed, 250.4x and combination code from 403 or 404 – 5th digit indicates presence of renal failure • Example: Progressive diabetic nephropathy with hypertensive renal disease and renal failure – 250.4x – 583.81 – 403.91 1/18/2008 ILEM, EdD, RHIA Neural Complications • When specific neurological complication is documented, assign that specific code • Neuropathy, Peripheral – Common DM complication – 250.6x, 357.2 • Neuropathy, Autonomic – Must be specifically state by Dr to code – 250.6x, 337.1 • Neuropathy, Cranial – 250.6x, 378.51 1/18/2008 ILEM, EdD, RHIA Diabetic Vascular Disease • Peripheral vascular disease – Frequent complication – 250.7x, 443.81 • CAD, cardiomyopathy, cerebrovasular disease are NOT DM complications – Code separately, UNLESS Dr documents causal relationship. 1/18/2008 ILEM, EdD, RHIA Other DM manifestations • Ulcers of lower extremities – Common DM complications – Result from diabetic neuropathy OR peripheral vascular disease – 250.6x OR 250.7x, 707.1x, – add 785.4 when gangrene present • *NOT all ulcers in DM pts are diabetic ulcers – Query Dr if relationship unclear in 1/18/2008 ILEM, EdD, RHIAdocumentation Other manifestations • Organic impotence – Results from diabetic peripheral neuropathy OR peripheral vascular disease – 250.6x OR 250.7x, 607.84 • When documentation of these two conditions does NOT indicate neuro or vascular causation, then code – 250.8x 1/18/2008 ILEM, EdD, RHIA DM and Pregnancy* *DM ALWAYS complicates pregnancy • Gestational DM • DM mother • Late pregnancy (24 28 wks) • Do NOT use 648.8x for mother dx with DM BEFORE the pregnancy • 648.8x • NO 250.xx code 1/18/2008 ILEM, EdD, RHIA • 648.0x, 250.xx Neonatal conditions associated with maternal DM • 775.0 or 775.1 • 775.1 may require a course of insulin • Assign ONLY when maternal condition has actually affected baby • Normal infant of DM mother • V30.00, V18.0 1/18/2008 ILEM, EdD, RHIA Hypoglycemic Reactions Can occur in diabetic OR non-diabetic patients • Diabetic pt – Occur when imbalance between patterns of eating/exercise and drug doses – New dx of type 1 DM, initial phase of tx – 250.3x with mention of coma – 250.8x w/o mention of coma 1/18/2008 ILEM, EdD, RHIA • Non-Diabetic Pt – 251.0 hypoglycemic coma – 251.1 specified hypoglycemia w/o coma – 251.2 hypoglycemia, NOS Hypoglycemia Adverse Effect or Poisoning • Due to drug used as prescribed – E code responsible drug • Hypoglycemic coma or shock – Incorrect use of anti-diabetic agent – 962.3, E858.0 1/18/2008 ILEM, EdD, RHIA 2ndary Diabetes • 250.xx codes NOT assigned • 251.3 Postsurgical hypoinsulinemia • Example: steroid-induced DM – 251.8, E932.0 1/18/2008 ILEM, EdD, RHIA Insulin use • V58.67 Long-term [current] use of insulin – – – – Usually secondary code Pt’s continuous use of a prescribed drug NOT used for drug addictions NOT used for temporary use of insulin to get glucose under control during an encounter • Pt routinely takes insulin (Type 1 OR 2 DM) • Pt taking insulin for gestational DM 1/18/2008 ILEM, EdD, RHIA Insulin Pump complications • 996.57 – used for failure or malfunction of pump that results in under/over dosing • 962.3 – used as additional code when mechanical complication results in OVERDOSE 1/18/2008 ILEM, EdD, RHIA Outpatient Settings • Code chronic DM conditions ONLY if relevant to service provided during visit • Example: Pt with high cholesterol, but no current medications for it. He comes in for tx of a closed fx of one rib. Dr. tx fx w/out manipulation. • Code(s)? 1/18/2008 ILEM, EdD, RHIA DM Example • Type 2 DM patient presents with acute extrinsic asthma attack. DM may put pt at risk for increased risk of infection and affects the Doctor’s choice of steroids for use as anti-inflammatory. • Codes? 1/18/2008 ILEM, EdD, RHIA Resources5 • AHA Coding Clinic – 2005, 1st Q, p. 44, 45 – 2004, 1st Q, p. 14-15 – 2002, 2nd Q, p. 13 – 1997, 4th Q, p. 33 – 1997, 2nd Q, p. 14 – 1993, 4th Q, p. 19 – 1991, 3rd Q, p. 8 1/18/2008 ILEM, EdD, RHIA Resources • Brown, Faye. 2005. ICD-9-CM Coding Handbook, with Answers. 2006 Rev. Ed. Chicago: AHA Press. • Green, Michelle A. 2007. 3-2-1Code It! New York: Thomson Delmar Learning. • MedlinePlus; a service of the US National Library of Medicine and the National Institutes of Health. http://www.nlm.nih.gov/medlineplus/ 1/18/2008 ILEM, EdD, RHIA References 1Mathur, R. Diabetes Mellitus. Medicinenet. http://www.medicinenet.com/ Accessed: 1/6/08 2Frazier and Drzymkowski, Essentials of Human Diseases and Conditions, 3rd ed. 2004, St. Louis, Elsevier Saunders, p. 168. 3Pancreas. ( 2008). In Encyclopædia Britannica. Retrieved 1/6/08, from Encyclopædia Britannica Online: http://www.britannica.com/eb/article-9058232 4Gerbarg, Z. Diabetic Retinopathy: Documentation and Coding. MDQuickFax. 2006. Retrieved 1/6/08, from 5Howard, A. Coding for Diabetes Mellitus. For the Record, v17, no. 20, p. 45. (2005) 6Mathur, R. Diabetes Treatment. Medicinenet. hhtp://www.medicinenet.com Accessed 1/14/08 1/18/2008 ILEM, EdD, RHIA [email protected] 1/18/2008 ILEM, EdD, RHIA