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New Diagnosis Codes for Secondary Diabetes

August 26, 2008:

There’s a new ICD-9-CM category and 20 new codes describing secondary diabetes for fiscal 2009. Category 249 Secondary diabetes mellitus closely parallels category 250 Diabetes mellitus.

Secondary diabetes is not clinically classifiable as either type I or type II diabetes and is more accurately classified within a new category, similar in structure to category 250 and maintaining all the applicable manifestation codes. In addition, instructional notes at subcategories 249.4–249.8 direct the coder to “use additional code to identify manifestation.”

The two categories are also parallel in having complications such as ketoacidosis, hyperosmolarity, coma, and systemic manifestations reported by the fourth digit in the code assignment. The same, fifth-digit subclassifications for unspecified or controlled (0) and uncontrolled (1) status are reported with category 249.

The difference between category 250 and 249 is that codes from category 249 are coded secondary to the underlying condition responsible for precipitating the diabetes. An instructional note has been added to direct the coder to code first the underlying condition, as well as V58.67 Long-term current use of insulin, when warranted by those patients who require insulin. Index entries have been modified, and official coding guidelines will be updated accordingly.

Here are the steps to correctly reporting a diagnosis of secondary diabetes:

  • Code first the underlying condition that precipitated the diabetes.
  • Assign the appropriate secondary diabetes code to the fourth- and fifth-digit levels, specifying whether or not there is a complication of the disease and if the secondary diabetes is controlled or not.
  • Use an appropriate E code to identify causal therapeutic drug use, if necessary.

Secondary diabetes mellitus presents with the same symptoms as diabetes mellitus and also manifests in elevated blood sugar levels, inhibiting the patient’s ability to successfully metabolize carbohydrates, fats, and proteins. Secondary diabetes arises from defects in insulin production and secretion, or defects in the action of insulin, but as a result of another, underlying primary cause. This may be caused, for instance, when the islets of Langerhans, responsible for the production of insulin, are either absent or destroyed by events such as chronic disease, trauma, or surgical removal of the pancreas. Secondary diabetes can also result from other hormonal disturbances, such as Cushing’s disease or an excessive growth hormone production that results in acromegaly. This type of diabetes may account for 1 percent to 5 percent of all diabetic disease.

Normal fasting plasma glucose levels are less than 110 milligrams per deciliter (mg/dl). Diagnostic criteria for diabetes includes a fasting glucose level in excess of 126–140 mg/dl on two or more tests on two separate days or plasma glucose levels in excess of 200 mg/dl at two separate times during a glucose tolerance test.

Causal conditions include:

  • Other disease (e.g., Cushing’s syndrome, malignant neoplasm, and certain genetic disorders)
  • Late effects of long-term drugs or chemical exposures or use (e.g., thiazides, dilantin, and steroids)
  • Late effect of poisoning
  • Other primary systemic diseases
  • Malnutrition
  • Complications of an infectious process
  • Genetic disorders or syndromes
  • Hormonal disturbances
  • Adverse complication of a surgical procedure
  • Trauma or injury to the pancreas

Treatment of secondary diabetes involves treating the underlying cause, if possible. In some cases such as diabetes caused by adverse effect of medication or drugs, once the source is addressed, the diabetes will go away. When the underlying cause cannot be resolved or remains unidentified, the diabetes is treated similarly to primary diabetes, with consideration given to pre-existing comorbidities. In general, this treatment focuses on controlling the level of glucose (blood sugar) with a combination of diet and exercise, and it may involve insulin therapy and antidiabetic agents. Secondary diabetes carries the same risks as primary diabetes, including complications such as heart conditions, stroke, diabetic retinopathy, diabetic nephropathy and neuropathy, and sexual dysfunction.

Deborah C. Hall
Clinical/Technical Editor


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