Ophthalmology and Optometry Coding Alert

This diagnosis coding trick can help you avoid denials

You've found the correct ICD-9 code for diabetic retinopathy, but don't stop there or your claim will be incomplete - you must also pick a code that describes the kind of diabetes that caused the retinopathy.
 
Under the "diabetic retinopathy" (362.0x) heading, ICD-9 directs you to "Code first diabetes (250.5)," says Nancy Cockrell, CPC, insurance manager at Jackson Eye Associates in Jackson, Miss. Use code 250.5x (Diabetes with ophthalmic manifestations) as a primary diagnosis and use the diabetic retinopathy code as a secondary diagnosis, she says.
 
Choose among four possible digits (0, 1, 2 or 3) to put at the end of 250.5, Cockrell says. Each possible fifth digit describes a type of diabetes and whether it's controlled or uncontrolled. These fifth digits apply to all the codes in the 250.xx series (Diabetes mellitus):
   0 - Type II or unspecified type, not stated as uncontrolled 
   1 - Type I (juvenile type), not stated as uncontrolled 
   2 - Type II or unspecified type, uncontrolled 
   3 - Type I (juvenile type), uncontrolled. Be specific: CPT uses pancreatic beta cell function to distinguish Type I (250.x1 and 250.x3) from Type II (250.x0 and 250.x2). A Type I diabetes patient's pancreatic beta cells can secrete no insulin; in Type II diabetes, these cells are impaired but can still secrete some insulin. A Type I patient must use insulin; a Type II patient might use insulin, depending on the severity of the disease.
 
Best bet: The ophthalmologist is unlikely to be able to diagnose pancreatic cell function, but he should be able to determine which type of diabetes a patient is receiving treatment for after discussion with the patient,  Cockrell says. But keep in mind that if a patient is diagnosed and does not require insulin, you know it is definitely Type II - 250.x0 or 250.x2.
 
Example: A 70-year-old noninsulin-dependent patient is referred to an ophthalmologist for a suspected condition related to her diabetes mellitus. The ophthalmologist determines that she has proliferative diabetic retinopathy. You should report a primary diagnosis code of 250.50 (Diabetes with ophthalmic manifestations; type II or unspecified type, not stated as uncontrolled), and for the secondary diagnosis code you should report 362.02 (Proliferative diabetic retinopathy).
 
Problem: Even though ICD-9 instructs you to code this way, not all carriers agree, says Joy Maddox, coder for the Eye Center of North Florida in Panama City. "I don't ever use [the diabetes codes] first," she says. "We've never had to do that here. I just use 362.02."
 
Check with your carrier for its preference. If you're reporting just one code, report 362.02, since "that's the reason the patient is coming in," says Elizabeth Borgen, coder for [...]