Simplify Diabetes Coding With a Standard Definition of 'Control'

Need help? Use the ADA and AACE guidelines
You need to report uncontrolled diabetes (250.x2 , 250.x3) to justify some diabetic patient services, such as CGMS. Here's what you might be missing when considering whether a patient's diabetes is "uncontrolled."

The distinction between controlled and uncontrolled diabetes can be unclear when a patient's condition is well managed but lab results still don't meet clinical standards for control. Physicians within the same practice may find themselves using different criteria to determine control - and bending those criteria according to individual patient circumstances. Use of varying criteria is dangerous because it creates coding confusion and inconsistently labels patients' diabetes.

Make life easier: Assigning the fifth digit to 250.xx (Diabetes mellitus) would be "so much easier" if physicians would assign controlled diabetes consistently according to set guidelines, says Sherri L. Gerety, CPC, financial systems supervisor for Wichita Clinic, a large multispecialty clinic with four endocrinologists in Wichita, Kan.

Establish guidelines: The best way to achieve coding consistency and accuracy - not to mention proper diagnoses - is to set guidelines for determining diabetic control in your practice and make sure all providers and coders stick to them. Your providers may not want to follow any of the established guidelines, but you should arrive at some agreed-upon guidelines that can serve as a standard reference.

If your practice doesn't have standard guidelines in place for what constitutes controlled versus uncontrolled diabetes, now is the time to establish them.
Assign Uncontrolled for an A1C above 6.5
Now, the American Association of Clinical Endocrinologists (AACE) states you should assign controlled diabetes only when the patient's hemoglobin A1C result is less than 6.5 percent, says Anthony Azzi, MD, clinical endocrinologist with Raleigh Endocrine Associates in Raleigh, N.C.

The glycated hemoglobin A1C test provides a long-term average glucose level based on one blood draw - and is now the gold standard for determining control, Azzi says. "Our goal in this office is to get [patients] under 6.5," he adds.

Example: If a type II diabetic with no complications presents for a routine visit and the physician finds his A1C result is 6.4, you should report 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled). For a type II diabetic with an A1C result of 7.2, you should report 250.02 (... uncontrolled).

Another way: The American Diabetes Association (ADA) is still advising that a patient with an A1C result under 7.0 should qualify as a controlled diabetic, Azzi says. General practitioners may be more likely to adhere to the ADA's recommendation, but the strictest guideline for endocrinologists in this country is the one AACE established - an A1C result under 6.5, he says.

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- Published on 2004-10-19