CODING CORNER: Bust 6 Diabetes Coding Myths -- the Experts Weigh in

Think you can’t bill Medicare for 2 screenings per year? Here’s when you can

Did you know that $100 billion of direct and indirect U.S. healthcare costs per year are related to diabetes? With cash like that changing hands, even a few diabetes coding mistakes can cost your facility big.

At the national conference in Seattle, the American Academy of Professional Coders’ Sheri Bernard, CPC, CPC-H, CPC-P, gave attendees the lowdown on diabetes coding. Grab your fair share of that $100 billion by overcoming these common diabetes coding myths.

Myth 1: You can bill Medicare for only one diabetes screening per year.

Fact: Medicare reimburses for two diabetes screening tests per year if the patient has significant risk factors, such as pre-diabetes or dysmetabolic syndrome X (277.7), Bernard says. You should be seeing these diagnosis codes a lot because there are about 41 million pre-diabetics in this country. It means that the patient is headed toward diabetes but can be cured, Bernard says, and in the future we will see pay-for-performance issues tied to it.

To use 277.7, the doctor must document three of the following, Bernard says:

• Abdominal obesity (35-inch, 40-inch waist)
• Hypertension
• Fasting glucose of 110 or higher
• High triglycerides in cholesterol (bad cholesterol)
• Low HDL in cholesterol (good cholesterol).
If the doctor simply circles 277.7 without documenting at least three of the above, it’s not proper coding, Bernard says. And you shouldn’t automatically assign this diagnosis code if you see three or more of these factors in a medical record. Ask the doctor before you code.

Don’t use a screening test code if there has ever been a diabetes diagnosis or if the patient is presenting with acute symptoms and the screening is not “routine.” Medicare-approved screening tests include 82947 (Glucose; quantitative, blood [except reagent strip]), 82948 (…blood, reagent strip) and 82950 (…post glucose dose [includes glucose]). These tests are CLIA-waived, so be sure to append modifier QW (CLIA-waived test) to bill in the office, Bernard reminds coders.

Is this why you’re not getting paid? Don’t forget to append modifier TS (Follow-up service) if the test is a follow-up service for a pre-diabetic patient. That’s a big reason claims for twice-annual screenings for 277.7 patients get denied, Bernard says.
 
And don’t forget 36415 (Collection of venous blood by venipuncture) and V77.1 (Special screening for diabetes mellitus).

Myth 2: If the patient has been treated for a diabetes complication, you must always sequence the diabetes diagnosis code (250.xx) first.

Fact: When coding diabetes complications, always sequence 250.xx first with the following exceptions, Bernard says. Report the diabetes code secondarily for:

• insulin pump malfunction
• heart problems
• cerebrovascular problems
• decubitus ulcer.

Bonus CPT/ICD-9 coding scenario: A 76-year-old patient with type II diabetic polyneuropathy has a [...]

- Published on 2007-07-12