Medicare Compliance & Reimbursement

Solve the 337.1-vs.-357.2 puzzle with this easy-to-reference guide

You're going to have to look at the patient's symptoms and history to assign polyneuropathy or autonomic neuropathy ICD-9 codes.

When coding for a diabetic patient with diabetic neuropathy, "What is the difference between 337.1 (Peripheral autonomic neuropathy in disorders classified elsewhere) and 357.2 (Polyneuropathy in diabetes)?" asks Robert Jackson, MD, an internist at Dickson Medical Associates with 28 physicians in Tennessee. "I've called insurers, and the representatives say there's no difference in coverage."

Impact: Using 337.1 or 357.2 comes down to meeting ICD-9 requirements to code to the highest specificity possible, Jackson says.

To code correctly, follow these guidelines.

Step 1: Code the Diabetes First

You should report the primary or underlying disease causing the neuropathy or polyneuropathy first on the claim, says Susan West, RHIT, compliance auditor at Auditing for Compliance and Education (ACE) Inc. in Leawood, Kan. You should list the neurological manifestation (337.1 or 357.2) as a secondary diagnosis.

When coding for diabetic neuropathy, you will assign 250.6x (Diabetes with neurological manifestations ...) with the appropriate fifth digit, such as 0 (... type II or unspecified type, not stated as uncontrolled), as the primary diagnosis. Diabetes often causes neuropathy, which is a general term for peripheral nerve damage or destruction.

Rules: Adhere to these coding combinations:

1. Polyneuropathy (357.2) can only go with diabetes (250.6x).

2. But you can list neuropathy (337.1) with a primary diagnosis of diabetes (250.6x) or amyloidosis (277.30-277.39).

Step 2: Polyneuropathy = Peripheral Mononeuropathy

Before you nail down the neuropathy diagnosis, come to terms with the following vocabulary: Equate polyneuropathy with peripheral mononeuropathy. ICD-9 Coding Clinic lists 250.6x and 357.2 (Polyneuropathy in diabetes) as the codes for peripheral (or cranial) neuropathy (see "Fourth Digit 6: 250.6x" in 1991 third-quarter issue).

Step 3: Look for Digit Pain, Body Problems

To identify peripheral neuropathy (polyneuropathy) versus autonomic neuropathy supporting chart notes, focus on the patient's symptoms and the E/M service's details.

"The manifestations for peripheral and autonomic neuropathy are different," says Bruce Rappoport, MD, CPC, CHCC, a board-certified internist and medical director of Broward Health's Best Choice Plus and Total Claims Administration in Fort Lauderdale, FL. Base the coding on the history and physical exam findings, he says.

Use this breakdown as a guide:

• Peripheral neuropathy--digit pain

Symptoms: Think peripheral neuropathy when a patient has pain and numbness in her hands and feet. Patients typically describe the pain "as tingling or burning" and often compare the loss of sensation "to the feeling of wearing a thin stocking or glove," the Mayo Clinic says.

Causes: A patient may develop peripheral neuropathy due to traumatic injuries, infections, metabolic problems and exposure to toxins. "One of the most common causes of the disorder is diabetes," the Mayo Clinic says. "In many cases, peripheral neuropathy symptoms improve with time--especially if it's caused by an underlying condition that can be resolved."

Action: "If the physician's notes indicate a peripheral polyneuropathy (with no additional specificity), the coder must look to the 357.x (Inflammatory and toxic neuropathy ...) code range, depending on the underlying disease," says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, principal of MJH Consulting in Denver. You would use "2" as the fourth digit for diabetes.

• Autonomic neuropathy--body function problems

What it is: A patient with autonomic neuropathy has damage to the nerves that regulate involuntary body functions, including heart rate, blood pressure, perspiration and digestion, the Mayo Clinic says. "Autonomic neuropathy results in faulty communication between your brain and the parts of your body that your autonomic nervous system serves."

Symptoms: Patients may experience dizziness, digestive and urination trouble, and sexual difficulties.

To treat autonomic neuropathy, the physician addresses the underlying cause and manages the signs and symptoms.

Do this: "If the provider documents that the peripheral neuropathy involves the autonomic nervous system, the coder should look to 337.1," Hammer says.

Use V Codes for Very Accurate Education Claims

Question: An established patient with type II diabetes reports to the physician 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?

Answer: When the physician is present in the office, an E/M is the proper code for insulin pump education. Because 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 service

• 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: Although 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 during which the patient returns for pump adjustment and fitting. 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 physician 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 you report represents the patient's diabetes (250.xx).