250.00 Only Won't Cut It for Diabetic Patients With Ophthalmic Manifestations

Confirm to code the specific diabetic Dx your ophthalmologist is providing care for.

In case you're feeling uncertain about filing claims for patients with ophthalmic complications from diabetes, support yourself with diagnosis basics and an understanding of manifestations to ace diabetic patient coding. Read this article to know what ICD-9 codes you must choose.

1. Master Decimal Places for Dx

One of the most common mistakes coders make when filling a claim on a diabetic patient is reporting 250.00 (Diabetes mellitus without mention of complication) for the diagnosis. Code 250.00 on its own usually is not adequate to indicate the diagnosis of patients with diabetes. In its place, you must specify the precise type of diabetes for which the ophthalmologist is providing care.

Why? Medicare and other third-party payers need a highly specific diagnosis to validate payment. That means that you must pay adequate attention to the fourth and fifth places beyond the decimal point, which specify any complications and the exact type of disease.

Fourth place: The fourth place, or the first decimal place, specifies a complication. This includes ICD-9 codes 250.0x-250.9x. The complication indicator normally used in the ophthalmologist's office is 250.5x, which specifies ophthalmic manifestations.

Fifth place: The fifth place, or second decimal place, specifies the sub-classification of disease. In the case of diabetes, it is the "type," such as:
250.50 -- (Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled)
250.51 -- ( . . . type I [juvenile type], not stated as uncontrolled)
250.52 -- ( . . . type II or unspecified type, uncontrolled)
250.53 -- ( . . . type I [juvenile type], uncontrolled).

Remember: The diabetes ICD-9 codes are not based on whether or not the patient is insulin dependent or non-insulin dependent, however whether or not it is type I or type II diabetes. In case you are uncertain, the unspecified code 250.50 would be the right choice -- in case the patient has some manifestations of the illness.

Watch out: Payers may reject your claim if your diagnosis code doesn't match up with the diagnosis code the patient's primary care physician (PCP) uses. For example, should the PCP use 250.41 (Diabetes with renal manifestations) to describe a patient's diagnosis and you put 250.00 on your claim, the inconsistency could trigger payer questions. But it is more precise to report ICD-9 code 250.5x as the primary diagnosis and reason for the encounter with the ophthalmologist.

Your claim may also demonstrate secondary diabetes diagnosis ICD9 codes when known.

2. Make Underlying Disease Primary Dx

Some coders are unsure how to code for diabetic patient care once the patient's primary physician hasn't so far diagnosed the disease.

You be the coder: The ophthalmologist discovers diabetic retinopathy in a patient identified as "pre-diabetic." Would you code 250.5x for diabetes along with ophthalmic complications, and 362.0x for the diabetic retinopathy or simply code for retinopathy since the PCP hasn't formally diagnosed the patient as diabetic?

Answer: Accurate medical coding requires you to report the 250.5x diagnosis as primary, then the retinopathy 362.0x diagnosis as secondary whether the patient has officially been diagnosed with diabetes or not.

Why? Diabetic retinopathy is evidently a manifestation of the much larger systemic disease of diabetes, so you must identify diabetes as the primary diagnosis.

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