Internal Medicine Coding Alert

Question: An established patient with type II diabetes reports to the internist for initial insulin pump education. Our nurse practitioner (NP) explained the differences in the pumps to the patient, and the patient selected the pump he felt most comfortable with. The NP then trained the patient on how to use the pump and set up an educational video for him to view. The physician was present in the office suite and available during the entire encounter. What is the proper coding for this scenario?

Montana Subscriber

Answer: When the physician is present in the office, an E/M is the proper code for insulin pump education. Since the NP was following an established plan of care and there was a physician immediately available, you can code the service incident-to the supervising physician.

And for the most accurate claim, you should use one standard ICD-9 code to reflect the patient's condition and a V code to explain the reason for the encounter.

Suppose the NP's service reflects a level-two E/M. On the claim, report the following:

• 99212 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: a problem-focused history; a problem- focused examination; and straightforward medical decision-making) for the E/M.

• 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled) linked to 99212 to represent the patient's diabetes

• V65.46 (Encounter for insulin pump training) linked to 99212 to explain the reason for the E/M service.

Note: While you should rely on V65.46 for initial insulin pump encounters, represent the different stages of insulin pump treatment with other V codes:

• Use V53.91 (Fitting and adjustment of insulin pump) for encounters in which the patient returns for adjustment and fitting of the pump. So if the pump does not fit perfectly at first, and the patient has to come in for adjustment(s), this is the proper ICD-9 code.

• Use V45.85 (Insulin pump status) for other follow-up visits, such as when the patient returns to the internist to get a progress report, or to change the pump's settings.

Remember: These V codes should be secondary diagnoses on any claim related to the insulin pump. Regardless of the V code, make sure the primary diagnosis represents the patient's diabetes (250.xx).