Puzzled by Diabetes Coding?
Test Your Diabetes Coding Know-how
By Sheri Poe Bernard, CPC, CPC-H, CPC-P
You probably think your knowledge of one of the most common diseases in the United States is complete. Here’s a quick true/false quiz to test that premise.
True or false?
- Abnormally high blood glucose is the hallmark of all types of diabetes.
- Diabetes mellitus is caused by eating too much sugar.
- Type I diabetics are insulin dependent; Type II diabetics are not.
- If the chart says “diabetes” without any more detail, the default diagnosis is always 250.00 Diabetes mellitus, type II, not stated as uncontrolled.
- A patient with a documented blood sugar of 400 should be classified as “uncontrolled.”
- Post-pancreatectomy is a form of secondary diabetes and would be reported with a code from the 249 Secondary diabetes category.
Let’s explore the answers.
Abnormally high blood glucose is the hallmark of all types of diabetes.
Answer: False. Diabetes incipidus does not cause hyperglycemia.
Diabetes has its roots in a Greek word for “that which passes through,” and refers to frequent urination. All types of diabetes have a clinical picture including polyuria. “Mellitus” has its root in the Latin word for “honey,” indicating sweet urine. “Insipidus” has its roots in Latin for “devoid of interest or taste.”
Diabetes insipidus (DI) is an endocrine disorder associated with the antidiuretic hormone, vasopressin. It can be caused by problems in the pituitary gland or the kidneys. Blood sugars are not affected, and so DI should never be reported using the codes for diabetes mellitus (DM). In DI, the body is unable to concentrate urine in the kidneys and shunts all fluids there. The patient with untreated DI is constantly drinking, and constantly producing very dilute urine.
DI may be due to a deficiency in the pituitary gland and production of vasopressin, reported with 253.5 Disorders of the pituitary gland and its hypothalamic control; diabetes insipidus. It can also be attributed to vasopressin resistance caused by a kidney disorder, which is reported with 588.1 Disorders resulting from impaired renal function; nephrogenic diabetes insipidus. These conditions may be chronic, or may resolve with treatment (for example, excision of a pituitary tumor). They can be treated with administration of vasopressin, usually through nose drops.
Diabetes mellitus is caused by eating too much sugar.
Answer: False. Diabetes mellitus is not caused by eating too much sugar or too many simple carbohydrates.
Type II DM occurs when the insulin-producing cells within the pancreas can no longer produce enough insulin, or when the insulin produced is not delivered efficiently to where it is needed. It can be caused by obesity (pancreas can’t produce enough); age (pancreas isn’t as efficient); or genetics (the system breaks down). Consumption of sugar or other simple carbohydrates will not cause diabetes, although overeating can lead to obesity, which can cause Type II diabetes.
Type I diabetics are insulin dependent; Type II diabetics are not.
Answer: False. Type I diabetics are insulin dependent, but Type II can be insulin dependent or not.
Type I DM is an autoimmune disease that destroys the patient’s ability to produce insulin. During the early stages of the disease, the patient may produce some insulin, but eventually none is produced. Type I diabetics are always insulin dependent. Type II diabetics can often control their blood sugars with a combination of diet, exercise, and oral medication. Some Type II diabetics cannot control their blood sugars except through insulin injections. Some Type II diabetics are insulin dependent, and for them, V58.67 Long term current use of insulin is reported secondarily.
If the chart says “diabetes” without any more detail, the default diagnosis is always 250.00.
Answer: False. This one is almost always true, but you need to watch for the exceptions.
If the chart says “diabetes” without any more detail, the default diagnosis is 250.00, unless the patient has diabetic ketoacidosis (DKA). With DKA, the diagnosis of “diabetes” defaults to Type I, since most diabetics who develop DKA are Type I diabetics.
DKA occurs when a shortage of insulin causes the body to break down fat and muscle for energy. The byproduct of this process is ketones, which enter the bloodstream and cause a dangerous form of acidosis. In DKA, the patient is severely dehydrated and confused. Due to the electrolyte imbalance caused by DKA, hospitalization is required to stabilize the blood chemistry and restore hydration.
A patient with a documented blood sugar of 400 should be classified as “uncontrolled.”
Answer: False. The only time it is appropriate to use fifth digits 2 (type II, uncontrolled) or 3 (type I, uncontrolled) is when the clinical documentation supports a diagnosis of “uncontrolled.” Terms like “poorly controlled” do not qualify as uncontrolled, either. If you have any concerns about the status of the patient, query the clinician. A “normal” blood sugar range varies greatly from patient to patient. Only clinicians familiar with their patient’s hemoglobin patterns can assign a diagnosis of “uncontrolled.”
Post-pancreatectomy is a form of secondary diabetes and would be reported with a code from 249.
Answer: False. The removal of a pancreas does have the secondary effect of causing diabetes, since the production of insulin is stopped. This makes pancreatectomy a form of secondary diabetes. However, ICD-9-CM classifies this form of secondary diabetes to 251.3 Other disorders of pancreatic internal secretion; Postsurgical hypoinsulinemia to segregate iatrogenic hypoinsulinemia from that caused by infection or disease of the pancreas.
Know the Who, What, and When of Diabetes Screening
The Centers for Disease Control (CDC) recently announced the number of diabetics in the United States exceeds 24 million people —that’s more people than the population of New York City—in fact, more than the entire state of New York. Another 57 million are estimated to have pre-diabetes, a condition with impaired glucose tolerance.
Diabetes interferes with a patient’s ability to convert food into energy, resulting in elevation of glucose in the blood and urine. In Type I diabetes (250.x1, 250.x3), an autoimmune disorder destroys all insulin-producing cells and the patient must inject or inhale insulin to survive. In Type II diabetes (250.x0, 250.x2), age, weight, or genetic predisposition hobbles insulin production or transportation, so control of blood sugar is hindered. Some Type II patients control their diabetes with diet, while others require oral medications or insulin. Secondary diabetes (249.xx) occurs when a drug, infection, or other issue reduces insulin efficiencies in the body.
Patients can live for many years without knowing they have Type II diabetes. Untreated or uncontrolled Type II diabetes can lead to complications affecting the eyes, circulatory system, kidneys, and nerves. Screening programs are an important component of pay for performance, but Medicare’s Physician Quality Reporting Initiative (PQRI) currently has no performance measure associated with early diagnosis and treatment to mitigate long-term complications of diabetes. PQRI has plenty of measurements for patients already diagnosed with diabetes, but nothing for diabetes screening. Watch for it in the future.
Diabetes screening involves testing the blood glucose level of patients without symptoms or history of diabetes. Because the symptoms associated with undiagnosed Type I diabetes are life-threatening, these patients typically are diagnosed during emergency care, not a routine screening test. Diabetes screening campaigns target asymptomatic Type II diabetes.
Physician coders can safeguard provider’s resources by knowing the who, what, and when of diabetes screening payments, and ensuring accurate and appropriate coding.
Medicare covers diabetes screening tests for patients with pre-diabetes, high blood pressure, high cholesterol, a BMI of greater than 30 or any two of the following: BMI of 25-29; family history of diabetes; age of 65 or greater; or a history of gestational diabetes. Some private plans now pay for diabetes screening tests in patients who are 45 years or older, a protocol recently endorsed by the American Diabetes Association.
Ethnicity plays a role in adults who have diabetes too, with American Indians and Alaska Natives an incidence of diabetes of 16.5 percent; blacks, 11.8 percent; Hispanics, 10.4 percent; Asian Americans, 7.5 percent; and whites, 6.6 percent. The CDC reports 25 percent of the population over the age of 60 had diabetes in 2007, and diabetes is the seventh leading cause of death in the nation.
For Medicare, claims for diabetes screening tests should link the diagnosis V77.1 Special screening for diabetes mellitus with one of the following CPT® procedures:
82947 Glucose; quantitative, blood (except reagent strip)
82950 Glucose; post glucose dose (includes glucose)
82951 Glucose; tolerance test (GTT), three specimens (includes glucose)
If a patient is diagnosed with pre-diabetes, the CPT® code should be reported with modifier TS Follow-up service. This allows CMS to more accurately track the pre-diabetic patients’ screening, and also allows for higher frequency of the screening.
Screening for pre-diabetic patients is reimbursed at the highest frequency: once every six months by Medicare. Patients who qualify for screening but are not pre-diabetic may be tested once annually. The private plans for screenings of 45-year-old or older patients generally cover once every three years, unless other conditions provide medical necessity for annual testing.
Do the math: How many patients in your practice are over the age of 65, obese, or experience elevated cholesterol or blood pressure? Unless you work in a pediatric clinic, the lion’s share of patients may fall into the category qualifying them for diabetes screening tests. Are these tests scheduled, documented, and billed with the frequency you would expect? Even at a reimbursement rate of $25, your practice may be leaving a lot of money—and a lot of preventive care—on the table if you aren’t performing diabetic screenings routinely.
For more information on diabetes screening, see MLN Matters article SE0821 and Job Aid JA0821 on the CMS website.