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Family Practice Coding Alert

Successful Diabetes Coding Requires a Fifth Digit

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.
Check Manual's 250 Section  
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 [...]