Anesthesia Coding Alert

Double-Check Diagnoses for Diabetic Neuropathy

Published on Fri Aug 08, 2003

Coding and reimbursement for diabetes care is challenging, partly because the patient often has multiple diagnoses and treatments related to the diabetes that you must consider. One key factor in correctly coding these patients' pain-management treatments is familiarity with the many diabetes diagnosis codes.

Start by Knowing Whether It's a Consult or Referral

Almost half of diabetes patients have diabetic neuropathy, a nerve disorder caused by the disease. The patient loses sensation in the feet (and possibly the hands) and has foot pain and weakness. Numbness, pain or tingling in the hands, feet or legs is often the first sign of diabetic neuropathy. The condition can move slowly, taking years to lead to conditions such as foot muscle weakness. Occasionally, the condition suddenly flares up and affects a specific nerve, causing additional weakness or pain.

"The endocrinologist will manage the patient as long as he feels comfortable doing so," says Barbara Johnson, CPC, MPC, anesthesia coder with Loma Linda University Medical Anesthesiology Group in Loma Linda, Calif. "He might refer the patient to a pain management specialist for a consult and then follow the specialist's recommendations. If that fails, he would probably refer the patient to a pain specialist to care for that portion of her medical problems."

If the patient's initial visit to the pain physician qualifies for an office visit code, start by determining whether it was a consult or a visit/referral. A consult happens when the anesthesiologist sees a patient and recommends something related to treatment. A visit or referral, on the other hand, happens when another physician sends the patient to the anesthesiologist for treatment.

Code a new or established patient office consultation with the appropriate choice from 99241-99245 (Office consultation for a new or established patient); choose from 99251-99255 (Initial inpatient consultation for a new or established patient) for an inpatient consult. If the patient encounter is a visit/referral instead of a consult, choose from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient) or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient).

Know the Type of Pain

When you're coding for diabetic neuropathy treatment, you should understand the type of pain the patient is experiencing. Neuropathic pain can have up to three different components:

ongoing pain that is continually present regardless of what the patient does or does not do

spontaneous pain episodes that suddenly appear without any identifiable stimulus

hyperalgesia, in which the patient has pain from an external stimulus that normally causes little or no pain (such as heat or cold).

In addition to being categorized by the type of pain experienced, the affected body area helps classify diabetic neuropathy. These include:

Peripheral neuropathy, which causes pain or loss of feeling in the toes, feet, legs, hands and arms. This type of neuropathy is extremely common, Johnson says.

Autonomic neuropathy, which causes changes in digestion, bowel and bladder function, sexual response, and perspiration. It can also affect the nerves that serve the heart and control blood pressure.

Proximal neuropathy, which causes pain in the thighs, hips or buttocks and leads to weakness in the legs. Some people call this polyneuropathy since it involves two or more extremities.

Focal neuropathy, which leads to sudden weakness of one nerve or group of nerves and causes muscle weakness or pain. This type of neuropathy can affect any nerve in the body.

Track Down the Best Diagnosis Code

Physicians often indicate that the patient has diabetic neuropathy without being more specific, says Susan West, CPC, a coder and auditor with the consulting firm Auditing for Compliance and Education in Leawood, Kan. But coders need more than that to make sure claims get filed and reimbursed correctly.

"You must submit an appropriate ICD-9 diagnosis code with each claim," West says. "Otherwise, the claim might be denied, or processing may be delayed. One of our biggest challenges is educating the physicians about the need to clarify the patient's specific diagnosis so we can assign a proper ICD-9 code."

As with any condition, code the diagnosis based on the highest level of specificity documented. The code for diabetic neuropathy (250.6x, Diabetes with neurological manifestations) isn't complete without a fifth digit, but West says she often finds that the correct fifth digit hasn't been assigned. Remember these fifth-digit classifications when coding for any diabetes patients:

0 - Type II (non-insulin dependent type) (NIDDM type) (adult-onset type) or unspecified type, not stated as uncontrolled. Fifth-digit 0 is for use for type II, adult-onset diabetic patients, even if the patient requires insulin.

1 - Type I (insulin dependent type) (IDDM) (juvenile type), not stated as uncontrolled

2 - Type II (non-insulin dependent type) (NIDDM type) (adult-onset type) or unspecified type, uncontrolled. Fifth-digit 2 is for use for type II, adult-onset diabetic patients, even if the patient requires insulin.

3 - Type I (insulin dependent type) (IDDM) (juvenile type), uncontrolled.

West adds that a secondary code for the disease manifestation often isn't included on the encounter forms, although it's needed. Report diagnosis code 357.2 (Polyneuropathy in diabetes) or 337.1 (Peripheral autonomic neuropathy in disorders classified elsewhere) in addition to the primary diabetic neuropathy code 250.6x.

Know Your Treatment Blocks

Once a patient comes to a pain specialist, the actual treatment depends on the specific area affected and the type of pain experienced. Johnson says that these factors plus the patient's pain threshold and how the patient reacts to medications determine how often the physician administers treatments.

The physician may administer corticosteroid injections or perform surgical decompression to treat entrapment neuropathies. Report this service with the appropriate neuroplasty code from 64702-64726 (codes related to Neuroplasty; Neuroplasty, major peripheral nerve, arm or leg; Neuroplasty and/or transposition; and Decompression), depending on the nerve treated. He may also perform nerve blocks to temporarily interrupt the conduction of impulses in peripheral nerves or nerve trunks created by the injection of local anesthetic solutions. These injections can serve as any of the following:

Diagnostic blocks to determine the pain source (i.e., to identify or pinpoint a nerve that acts as a pathway for pain) and to determine the type of nerve that conducts the pain. Diagnostic blocks also help distinguish whether the pain is central (within the spinal cord) or peripheral (outside the spinal cord) in origin and determine whether the physician should administer a neurolytic block or perform surgical lysis of the nerve. West says the physician may inject saline to stimulate pain or inject an anesthetic agent to evaluate the patient's response. Coding this can be tricky because no specific code exists. Your best bet may be 90799 (Unlisted therapeutic, prophylactic or diagnostic injection) since it's a diagnostic procedure.

Johnson says you would normally look at 64450* (Injection, anesthetic agent; other peripheral nerve or branch) when the physician treats diabetic neuropathy. Some carriers might question this, however, because the physician injects saline during the procedure instead of an anesthetic agent. Check with your carriers about coding these blocks. This initial diagnostic step helps physicians determine what the best pain relief options may be.

Therapeutic blocks to treat painful conditions that respond to nerve blocks. You have many CPT codes to choose from, depending on whether it is an injection to a particular site or administration of a neurolytic. Common options include 64400-64530 (various locations for somatic and sympathetic nerve injections) when the physician injects an anesthetic to block nerve conduction and provide short-term or complete pain relief, West says.

Prognostic blocks to predict the outcome of long-lasting interventions such as infusions, neurolysis or rhizotomy. Report these services with the appropriate code for nerve destruction by neurolytic agent - chemical, thermal, electrical, radiofrequency or chemodenervation - depending on the type of nerve, treatment site and injection level. Coding possibilities include somatic nerve destruction codes 64600-64640 and sympathetic nerve destruction code 64680 (Destruction by neurolytic agent, celiac plexus, with or without radiologic monitoring) for neurolytic destruction. Code rhizotomy with 64622 (Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level) or 64626 (... cervical or thoracic, single level) as appropriate.

Don't Forget the Specialty Code

Because the patient continues seeing his or her endocrinologist or primary-care physician for other aspects of diabetes care, work with that physician to ensure you code services correctly. Some carriers may deny claims if multiple physicians caring for the patient use the same diagnosis code.

You can avoid this by reporting the correct physician specialty code to differentiate your physician's services from the endocrinologist's or primary-care physician's.

The anesthesiologist's specialty code is "05." West says pain management physicians now have two specialty codes to choose between: "72" for pain physicians and "09" for an interventional pain physician. Know which specialty code applies to your physicians so you can report it correctly. A pain specialist is a board-certified physician who studies pain and performs manipulations and small injections (such as trigger points or joint injections). An interventional pain specialist is board-certified to administer injections; the physician must be an interventional specialist to use fluoroscopy and administer spinal, facet, epidural and SI joint injections.