Briefing: Practical Information on Diabetes Coding Date: 21 March 2007 Time: 1300-1350

1. Briefing: Practical Information on Diabetes Coding Date: 21 March 2007 Time: 1300-1350

2. Objectives • You will learn: • How to select the correct diagnosis and match the medical necessity code for routine office visits, education, and procedures • CPT and HCPCS procedures, supplies, training, education, and office visits

3. Why • Diabetes coding impacts multiple disciplines, including but not limited to: internal medicine, family practice, pediatrics, podiatry, optometry/ophthalmology • Fast growing disease

4. Documentation • Who – The individual who treated the patient • What – History/exam/decision making, what happened, what you did • When – As close to the encounter as possible • Where – Medical record: It could be inpatient or outpatient doctor’s note • Why – Continuity of care, for billing purposes, to protect yourself • How – Paper, computer/electronic, transcription; requires legibility

5. Coding Systems • ICD-9-CM • Diagnoses • Medical necessity • CPT • Office visits/rounds • Procedures • HCPCS • Education • CMS specific • Supplies/Equipment • Location • Number of bedrooms • Brick with gas range

6. International Classification of Diseases (ICD) • Diabetes is not coded with just the 250.xx codes • When coding manifestations, code the underlying cause first – in this case diabetes • Gestational diabetes is coded using the obstetrical 648s, not the 250s

7. Metabolic Syndrome • The metabolic syndrome is characterized by a group of metabolic risk factors in one person.  They include: • Central obesity (excessive fat tissue in and around the abdomen) • Atherogenic dyslipidemia (blood fat disorders — mainly high triglycerides and low HDL cholesterol — that foster plaque buildups in artery walls) • Insulin resistance or glucose intolerance (the body can’t properly use insulin or blood sugar) • Prothrombotic state (e.g., high fibrinogen or plasminogen activator inhibitor [–1] in the blood) —Continued—

8. Metabolic Syndrome • Raised blood pressure (130/85 mmHg or higher) • Proinflammatory state (e.g., elevated high-sensitivity C-reactive protein in the blood) • The underlying causes of this syndrome are overweight/obesity, physical inactivity and genetic factors. People with the metabolic syndrome are at increased risk of coronary heart disease, other diseases related to plaque buildups in artery walls (e.g., stroke and peripheral vascular disease) and type 2 diabetes

9. Metabolic Syndrome • Presence of three or more of these components: • Central obesity as measured by waist circumference: • Men — greater than 40 inches; Women — greater than 35 inches • Fasting blood triglycerides greater than or equal to 150 mg/dL • Blood HDL cholesterol: • Men — less than 40 mg/dL; Women — less than 50 mg/dL • Blood pressure greater than or equal to 130/85 mmHg • Fasting glucose greater than or equal to 110 mg/dL

10. 2007 ICD-9-CM Diagnosis 277.7 • Dysmetabolic Syndrome X • A multifaceted syndrome characterized by hyperinsulinemia, dyslipidemia (hyperlipidemia), essential hypertension, abdominal obesity; and glucose intolerance in individuals with insulin resistance. It is different from microvascular angina (cardiac syndrome X)

11. Medical Necessity • Documentation must show reason • Coding must show reason linked to the service provided, prescription/lab/radiology study ordered

12. Sequencing • Sequencing diagnoses/reasons for encounter • First: primary reason for encounter • Subsequent: other conditions/co morbidities impacting this episode of care: • Education • Hypertension • Hypercholesterolemia • Obesity • Tobacco use disorder

13. Common Diabetic Related Diagnoses • See handout “Common Codes” • When coding diabetic manifestations, • Code the 250.XX first (e.g, 250.6x, neurologic) • Then code the manifestation (e.g., 357.2 polyneuropathy) • V58.67 Long-term (current) use of insulin • Just for type II who are unable to control their blood sugar through diet and oral medication alone • If patient is pregnant, use the 630-677 codes, providing: • Condition impacts the pregnancy • Condition is impacted by the pregnancy

14. Review Time • Patient presents with “my top back teeth hurt and when I bend over to tie my shoes, it feels like my head will explode” • Patient is diabetic; hypertensive; has clear, yellow post nasal drip; obese; smokes; and is allergic to cats • Doctor diagnoses: sinusitis, hypertensive, type II diabetes - controlled, tobacco use disorder • Provide training on using sterile water upon first symptoms of sinus infection, sinusitis medication, and refill anti-hypertension medications

15. Review Time • Chief Complaint = First Diagnosis • 461.9 Sinusitis, acute, unspecified • Second and subsequent diagnoses which impact the encounter • Patient is diabetic; hypertensive; has clear, yellow post nasal drip; obese; smokes; and is allergic to cats • Doctor diagnoses: sinusitis, hypertensive, type II diabetes – controlled, tobacco use disorder • 401.9 Hypertension, NOS • 250.00 Diabetic type II • 305.1 Tobacco use disorder (perhaps, don’t know how it impacted encounter) • Don’t code • Post nasal drip – code symptom only if no diagnosis • Obesity – did not impact encounter • Allergy to cats – did not impact encounter

16. Current Procedural Terminology (CPT) • Mostly use E&M based on documentation • For Certified Diabetic Educators – look at 98960-98962 • Many new category II codes this year

17. Office Visits • Chief Complaint – Ensure this is documented • New patient • Has not received care from practice in 3 years • Established Patient • Has received care within past 3 years by someone in the practice (even if that provider is no longer with the practice) • History • Exam • Decision Making • Time • Modifier 25

18. Office Visits • History • History of present Illness – OPQRST (onset, palliative / provocative, quality, radiation of pain, severity, time of day) • Review of systems • Past family and social history • Decision Making/Risk • Diagnoses impacting encounter • Management options • Data reviewed • Risk

19. Telephone Calls • For discussing new problem • Not for continuation of prior encounter, such as calling to give laboratory results • If a privileged provider interacts with the patient, and they come to a decision on care management, it is codable using 99371-99373 • If only nurse interacts, then to make it a legal medical record, the nurse must sign and code it – not a privileged provider • Nurses use 99499

20. Consults versus Referrals • Consult – provider retains control of patient • Written request • For advice • With written reply • Can be inpatient or outpatient • Outpatient - 99241-99245, Inpatient 99251-99255 • Referral – sends patient to another provider for care of that condition, does not retain control of patient • Coded as an office visit, usually “new office visit”

21. Inpatient • 99221-99223 Initial • 3 of 3 key components • 99231-99233 Subsequent • 2 of 3 key components • 99238-99239 Discharge, based on time • 99238 – 30 or fewer minutes • 99239 – more than 30 minutes

22. Physicals • Involve comprehensive history and exam for that type of physical (e.g., well woman and periodic diabetic may not require same history and exam) • Counseling, anticipatory guidance and risk factor reduction • Unlike office visits with medical decision making • 99381-99387 New patient physical • 99391-99397 Established patient physical

23. Prevention • Counseling and risk factor reduction without the history and exam • Not to be used for education (where there is a sign, symptom or established condition, such as diabetes) • If the encounter is not for diabetes, but for healthy eating, or stress management without symptoms, consider: • 99401-99401 – Based on amount of time • 99411-99412 – Groups, based on time

24. Education – Diabetes • Education • Sign, symptom or established condition • Diagnosis will be the condition, sign or symptom (e.g., diabetes, obesity) • Use 99078 or HCPCS code • Frequently not paid by insurer, considered part of care for the condition • Counseling • No established condition • Done to prevent a condition from occurring • Diagnosis, see V65.4X codes

25. HCPCS • Centers for Medicare and Medicaid Services • Non-physician type services, supplies, equipment, dental codes • Some E&M with specific requirements for CMS • Some screenings (e.g., colorectal cancer) • 5 characters, first character = letter, second through fifth characters = numbers

26. HCPCS • Use CPT codes if language is the same • Use HCPCS if language is more detailed • See handout – “Common Codes”

27. HCPCS – Physician Voluntary Reporting Program Codes Report these codes in addition to office visit, consult, home visit, nursing facility or initial preventive physical exam – at no additional charge

28. Bring it all together Influenza for an Adult • ICD-9-CM, Diagnosis • V04.81 – Need for prophylactic vaccination and inoculation against certain viral diseases – Influenza • CPT, Service Provided • 9920x, 9921x, Office visit or 9938x, 9939x for physical • 90471 – Administration of vaccine, for first non-nasal/non-oral vaccine, OR • 90473 – Administration of vaccine, intranasal or oral • 90660 – Influenza virus vaccine, live, for intranasal use • Supply item (vaccines and allergens are some of the few supplies in CPT) —Continued—

29. Bring it all together Influenza for an Adult • HCPCS (if the patient is only there for the vaccination) • G0008 – Administration of influenza virus vaccine when no physician fee schedule on the same day • G0009 – Administration of pneumococcal vaccine when no physician fee schedule service on the same day • See handouts