ICD-9 Coding Corner: Report Metabolic Syndrome, But With Caution

You shouldn't use 277.7 as primary Dx if the physician treats diabetes too
The new code on the block has rapidly gained popularity since it first stepped out in the 2002 ICD-9-CM. If you haven't acquainted yourself with 277.7 yet, now is the time.

Insurance companies were slow to acknowledge 277.7 when it first came out, leaving many claims up in the air, says Stephanie Swain, a coder with North Atlanta Endocrinology & Diabetes in Lawrenceville, Ga. But now, "I probably report it 25 times a month or so," and carriers don't have a problem with paying on the code, she says.

Definition: Dysmetabolic syndrome X (277.7) - also commonly known as metabolic syndrome - is in many ways a catch-all diagnosis, says Susan Spratt, MD, endocrinologist with Duke University Medical Center in Durham, N.C. Metabolic syndrome "is characterized by a group of metabolic risk factors in one person," such as obesity, dyslipidemia, insulin resistance or glucose intolerance and elevated blood pressure, according to the American Heart Association (AHA). "Underlying causes of this syndrome are overweight/obesity, physical inactivity, and genetic factors," the AHA states.

"Metabolic syndrome increases your risk for heart disease by about five fold, and it tells you that you need to be even more aggressive with all the risk factors for heart disease, like controlling lipids, blood pressure, and diabetes," Spratt says.

Action tip: Because metabolic syndrome may accompany many other metabolic disorders, you should report the specific condition the physician treats during the visit - such as diabetes (250.xx) or hypertriglyceridemia (272.1) - as the primary diagnosis code. Using the specific condition codes will offer your carriers the most detailed patient information.

Warning: Don't report obesity (278.0) as the primary diagnosis when the patient also has metabolic syndrome. Most times carriers will not pay on a claim for obesity, Spratt says.

Remember additional manifestations: If the physician is mainly treating the patient's metabolic syndrome, you should report 277.7 as primary and use additional codes to indicate related manifestations, such as cardiovascular disease (414.00-414.07), hypertension (401.9) or hyperlipidemia (272.4), Swain says.

- Published on 2004-09-23