Using the electronic medical records system at each site, we searched the following ICD-9-CM codes to identify possible visits for hypoglycemia: 250.3 (diabetes with other coma), 250.8 (diabetes with other specified manifestations) 251.0 (hypoglycemic coma), 251.1 (other specified hypoglycemia), 251.2 (hypoglycemia, unspecified), 270.3 (leucine-induced hypoglycemia), 775.0 (hypoglycemia in an infant born to a diabetic mother), 775.6 (neonatal hypoglycemia), and 962.3 (poisoning by insulins and antidiabetic agents).
Given the diversity of potential ICD-9-CM codes, we searched this broad range of codes and in all diagnosis fields (up to ten listed) in an attempt to capture all possible ED hypoglycemia visits. For admitted patients, we examined only ED-based codes, to avoid inclusion of incident hypoglycemia that occurred during inpatient hospitalization. In cases where multiple candidate codes were present, we recorded only the first-listed code. The exception to this was for the more ambiguous codes 250.3 and 250.8, for which we preferentially recorded any of the other candidate codes if present. We based this strategy on detailed examination of the ICD-9-CM coding manual [9 ], review of the experience from previously reported approaches [10 (link)-14 (link)], and discussion with coding experts.
The code 250.8 may be used for other specific diabetes-associated complications in addition to hypoglycemia, including: 259.8 (secondary diabetic glycogenosis), 272.7 (diabetic lipidosis), 707.xx (ulcers of the lower extremity), 709.3 (Oppenheim-Urbach syndrome), and 730.0–730.2, 731.8 (osteomyelitis). Based on discussion with coding experts, we determined that 681.xx (cellulitis of fingers/toes), 682.xx (other cellulitis), and 686.9x (local skin infection) may also be utilized as a co-diagnoses for 250.8, although not specifically mentioned in the manual. We prospectively proposed the coding algorithm displayed in Figure1 and validated its accuracy through chart review.
We identified all ED visits with candidate ICD-9-CM codes between July 1, 2005 and June 30, 2006 at each site, and obtained written ED charts. For patients with multiple ED visits during the data collection period, we requested only the first visit to avoid overrepresentation by certain patients. Trained research staff abstracted all charts using a standardized form, and the research group met weekly to discuss data collection and resolve abstraction issues. Additionally, two reviewers independently abstracted 10% of charts to evaluate inter-rater agreement in data collection. To enhance the reliability of our chart review, we abstracted only charts with complete ED triage assessment, nursing notes, and emergency physician notes and considered all other charts incomplete.
Given the diversity of potential ICD-9-CM codes, we searched this broad range of codes and in all diagnosis fields (up to ten listed) in an attempt to capture all possible ED hypoglycemia visits. For admitted patients, we examined only ED-based codes, to avoid inclusion of incident hypoglycemia that occurred during inpatient hospitalization. In cases where multiple candidate codes were present, we recorded only the first-listed code. The exception to this was for the more ambiguous codes 250.3 and 250.8, for which we preferentially recorded any of the other candidate codes if present. We based this strategy on detailed examination of the ICD-9-CM coding manual [9 ], review of the experience from previously reported approaches [10 (link)-14 (link)], and discussion with coding experts.
The code 250.8 may be used for other specific diabetes-associated complications in addition to hypoglycemia, including: 259.8 (secondary diabetic glycogenosis), 272.7 (diabetic lipidosis), 707.xx (ulcers of the lower extremity), 709.3 (Oppenheim-Urbach syndrome), and 730.0–730.2, 731.8 (osteomyelitis). Based on discussion with coding experts, we determined that 681.xx (cellulitis of fingers/toes), 682.xx (other cellulitis), and 686.9x (local skin infection) may also be utilized as a co-diagnoses for 250.8, although not specifically mentioned in the manual. We prospectively proposed the coding algorithm displayed in Figure
We identified all ED visits with candidate ICD-9-CM codes between July 1, 2005 and June 30, 2006 at each site, and obtained written ED charts. For patients with multiple ED visits during the data collection period, we requested only the first visit to avoid overrepresentation by certain patients. Trained research staff abstracted all charts using a standardized form, and the research group met weekly to discuss data collection and resolve abstraction issues. Additionally, two reviewers independently abstracted 10% of charts to evaluate inter-rater agreement in data collection. To enhance the reliability of our chart review, we abstracted only charts with complete ED triage assessment, nursing notes, and emergency physician notes and considered all other charts incomplete.
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