Primary Care Coding Alert

Most FPs report that many of their patients suffer from diabetes, which is not surprising because the American Diabetes Association (ADA) estimates that nearly 16 million Americans suffer from the disease and another 800,000 new diagnoses are confirmed each year. This chronic condition demands routine management and is often complicated by common illnesses like respiratory infections or gastrointestinal flu. To ensure appropriate payment from Medicare and commercial insurers, family practice coders must understand the intricacies of diabetes diagnosis coding, guidelines governing diabetes education reimbursement, and factors that determine which E/M codes should be assigned for routine care.

 
Perhaps the most important fact about diabetes diagnoses is that, without exception, they require a fifth digit. According to Debi Wagner, CPC, biller/coder for the Southern Ohio Medical Center in Portsmouth, most diabetes-related diagnoses may be found in the 250 (diabetes mellitus) section of the ICD-9 manual. Exceptions include gestational diabetes (648.8x) and neonatal diabetes mellitus (775.1). Various classifications and complications are identified with the fourth digit (e.g., 250.1, diabetes with ketoacidosis). "In addition, coders must add a fifth digit that identifies Type I or Type II diabetes and further indicates if the disease is controlled or uncontrolled," she says. "A lot of times, this information isn't clearly noted on the encounter form. The coder may need to seek out the physician and pinpoint the specific information necessary to determine which ICD-9 code to assign."
 
Note: A chart at the beginning of the 250 section of the ICD-9 manual explains how to assign the correct fifth digit.
 
Wagner warns that a diabetes code cannot be assigned until laboratory results confirming the diagnosis have been received. "For instance, a patient may come in with symptoms that strongly suggest diabetes -- dizziness (780.4, dizziness and giddiness), excessive thirst (783.5, polydipsia), frequent urination (788.41, urinary frequency) and a family history of the disease (V18.0). These symptoms will trigger testing for diabetes."
 
Coders would assign the appropriate E/M code (e.g., 99211-99214, office or other outpatient visit, established patient), along with glucose finger stick code 82962 (glucose, blood by glucose monitoring device[s] cleared by the FDA specifically for home use) or 82948 (glucose; blood, reagent strip), depending on the method the physician uses. Practices would report a code for urinalysis if one is done at that time (e.g., 81000, urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy). The codes that most accurately describe the symptoms would be linked to support medical necessity.
 
Note: Although CPT guidelines indicate that 81000 should be separately coded and paid, some insurers are bundling this service with E/M services provided on the same date, and thus denying separate reimbursement for the 81000. Coders should ask relevant medical directors for their payment policies.
 
If test results show sugar in the urine (791.5, glycosuria), further blood and urine testing may be done.

 
Initial patient care after diabetes has been diagnosed is intense, says Charles J. A. Schulte III, MD, FAAP, who practices with Countryside Pediatrics in Sterling, Va. "Physicians can expect to spend a lot of time with patients and their families, particularly if there is no history of diabetes in the family." Also, he notes there may be a sense of urgency in providing care, particularly if Type I, or juvenile, diabetes has been discovered. "Type II is a slow, insidious disease. But Type I is rapid onset. The patient may be well today, but in a coma tomorrow."
 
In most instances, a level-five office visit would be assigned (99205 or 99215), because of the complexity of the history, exam and medical decision-making, or because of the amount of time spent counseling the patient.
    
E/M code 99205 typically involves 60 minutes of face-to-face time with the physician, and 99215 typically involves 40 minutes of face-to-face time. If the physician spends more than half of that time in counseling, he or she may code the service on the basis of the total time spent with the patient. While 30 minutes beyond that typical time may not be separately coded and billed, Schulte notes that 30 to 74 additional minutes may be reported with 99354 (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour). Add-on code 99355 (... each additional 30 minutes) is assigned for even longer amounts of time spent with the patient.
 
Family physicians may also spend time on the phone with the patient or family members, especially during the first few weeks of treatment when the patient may need help with self-management techniques, e.g., monitoring blood sugar. These services may be reported with telephone codes from the case-management section of CPT. Depending on documentation confirming the nature of the call and the extent of the conversation, coders would assign 99371 (telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other healthcare professionals ...; simple or brief ), 99372 (... intermediate) or 99373 (... complex or lengthy). Unfortunately, most insurers do not pay for these codes. Medicare, for example, considers them bundled with other E/M services.
 
If the time spent on the telephone is significant and if calls occur shortly before an outpatient visit, physicians may factor the time into the next appointment. Coding professionals recommend that the phone call be documented and that the physician review topics discussed on the phone when performing the history at the appointment. This may increase the level of service and justify a higher level of E/M code.
    
Note: FPs may also elect to refer the patient to an endocrinologist for care or, if symptoms are severe, admit the patient to the hospital (99221-99223, initial hospital care).

 
Perhaps the most important element in treating diabetes is patient management of the disease. Educational programs, either one-on-one or in small groups, are designed to provide instruction of self-monitoring blood glucose, diet and exercise regimes to control the disease, and compliance to an insulin treatment plan customized to the patient. Two HCPCS codes may be used to report up to 10 hours of training provided to each Medicare patient:
 
G0108 -- diabetes outpatient self-management training services, individual, per 30 minutes
 
G0109 -- diabetes self-management training services, group session (2 or more), per 30 minutes.

 
Medicare will pay for these services only when they are provided through an accredited program (e.g., one certified by the American Diabetes Association's Education Recognition Program [ADA-ERP], which requires that both a registered nurse and a registered dietician be on staff). Sessions must be furnished in increments of no less than one-half hour. If education provided by a family practice does not meet Medicare's certification requirements, a beneficiary's secondary insurance may pay for the training. In these cases, charges would first be submitted to Medicare and, when denied, submitted to the secondary payer.
 
Commercial insurers may or may not pay for self-management training. If not, the patient may be billed directly.
 
Practices may be tempted to bill education provided by a nurse or dietician with an E/M code. But coding experts say E/M visits are defined as physician services and it is inappropriate to use the codes for nurse or dietician activities. The one exception to this occurs when the patient comes in expressly to meet with the nurse, when 99211 may be assigned. However, 99211 cannot be assigned on the same date of service with another physician-provided E/M service. Nor can time spent with a nurse or dietician at the end of the physician visit be added to the overall encounter to justify a higher-level E/M service.

 
A diagnosis of diabetes often affects coding and billing for other services the FP may provide to the patient -- from preventive-care visits to assessing and treating common illnesses like colds or the flu, Schulte says. Coders should be careful when coding three specific types of encounters with diabetic patients:
 
1) Regular appointments to manage the diabetes and monitor the effectiveness of treatment. Although these visits are considered routine, coders should not mistake them for preventive services. The appropriate office visit should be billed instead, e.g., 99213 as opposed to 99395, periodic preventive medicine, established patient; 18-39 years.
 
2) Problem-focused care of the diabetes provided during a bona fide preventive visit. For instance, a 60-year-old woman is seen for her annual checkup and, during the course of the visit, the physician also evaluates her diabetes. Both the preventive service (i.e., 99396) and the appropriate problem-focused E/M service (e.g., 99214) are reported. The outpatient visit would be appended with  modifier -25 to distinguish it as a significant and separately identifiable E/M service.
 
3) Problem-focused office visits that may be complicated by the diabetes. When diabetics present with symptoms of other illnesses such as a sore throat, the family physician will need to spend extra time to assess how the two conditions may affect one another. This extra time often includes additional consideration during the history and physical exam and may add complexity to the medical decision-making. These efforts will result in a higher level of service than may be typically reported for the presenting illness.