Ophthalmology and Optometry Coding Alert

America is being blinded by obesity

Coding for eye diseases related to diabetes presents a chicken/egg conundrum for coders: Should they report the eye disease as the primary diagnosis or the diabetes that caused it? With new cases of diabetes skyrocketing, coders and physicians had better get up to speed.
 
A recent Duke University study found that age-related eye diseases, including diabetic retinopathy, increased significantly during the 1990s.
 
The study findings, published in the September issue of the Archives of Ophthalmology, analyzed a national sample of Medicare beneficiaries aged 65 and older and recorded the incidence of diabetic retinitis, glaucoma and age-related macular degeneration.
 
During the study period, the prevalence of diabetes mellitus increased from 14.5 percent to 25.6 percent. Diabetic retinopathy cases among the 10,476 subjects increased from 6.9 percent to 17.4 percent.
 
The study concludes that "[t]he continued aging of the baby-boomer population will result in an even greater burden of eye disease in the United States than previous cross-sectional estimates indicated."
 
"This increased burden has important implications for the nation's public health, for resource allocation, and for the financing of vision care in the future. As more elderly individuals live longer, we may see a rise in the prevalence of chronic eye diseases that will significantly challenge our ability to provide care."
 
According to the American Diabetes Association, approximately 17 million people in the United States, or 6.2 percent of the population, have diabetes. Six million don't know they have the disease.
 
More than 1 million people aged 20 years or older are diagnosed per year. Those numbers will jump as the average age of Americans increases in the decades to come.

Diabetes Causes Blindness
 
Diabetes is a leading cause of new cases of blindness among adults 20-74 years old. Diabetic retinopathy causes from 12,000 to 24,000 new cases of blindness each year.
 
Diabetic retinopathy is the most common eye disease related to diabetes. The National Eye Institute estimates that between 40 and 45 percent of those diagnosed with diabetes have some degree of diabetic retinopathy. Between 600,000 and 700,000 Americans have diabetic retinopathy severe enough to cause vision loss. As many as 24,000 people go blind from this disorder annually, making it a leading cause of blindness among working-age Americans.
 
Two important risk factors increase the likelihood of diabetic retinopathy:

 1. Type of diabetes. People with type I diabetes are more likely to develop diabetic retinopathy than type II patients.
 2. Duration of disease. Virtually everyone who has had type I diabetes for 15 years or more has some degree of diabetic retinopathy.
 
As dire as these numbers are, early detection and frequent diabetic screenings can preserve diabetics' sight.

Diagnosis Coding the Diabetes

When you are diagnosing a diabetic patient, the first rule of thumb is to use the diagnosis code that best explains why you have seen the patient - but that's not always as easy as it sounds.
 
The diagnosis code will represent either diabetes without mention of complication, 250.0x, or diabetes with ophthalmic manifestations, 250.5x.
 
The fifth digit of the diagnosis code identifies whether the patient has type I or type II diabetes and whether it is "controlled" or "uncontrolled," nonspecific terms that indicate whether the patient's blood sugar level is kept within acceptable levels by his or her treatment regimen. The fifth digit is very important - it tells the carrier whether the patient has any ill effects visually from the diabetes.
 
If there is an ophthalmic manifestation of diabetes, ICD-9-CM instructs you to designate a second diagnosis code because chronic manifestations require a code from the 250.5x category in addition to a code that specifically identifies the manifestation.
 
Applying this second diagnosis is even required if the index does not indicate a need for dual coding. "When a patient comes in for an annual diabetic exam, you must document this as the reason they are in, but you can also document any symptoms they may have at the time, such as blurred vision, dry eye, etc.," says Sherry Searson, CPC, an independent coding consultant based in Charleston, S.C.
 
"This should get Medicare and most private insurers to pay for the exam based on medical necessity," Searson says. A caution to coders: Payers do not require the second diagnosis code of diabetes, and if it is added and is not to the highest level of specificity, it can cause a claim denial. There are also some payers who will not reimburse ophthalmologists when only diabetes is reported as the reason for being seen when used in conjunction with the eye codes (92002-92014, General ophthalmological services).

Examples of Diabetes-Related Coding
 
Here are some examples of coding ophthalmic manifestations of diabetes generated from the Northeast Health Care Quality Foundation Payment Error Prevention Program:
 
Example 1: A 70-year-old insulin-dependent patient is referred to an ophthalmologist for a suspected condition related to her diabetes mellitus. The ophthalmologist determines that she has proliferative diabetic retinopathy. You should report a primary diagnosis code of 362.02 (Proliferative diabetic retinopathy), and for the secondary diagnosis code you should report 250.51 (Type I insulin-dependent diabetes with ophthalmic manifestations).
 
Example 2: A 30-year-old non-insulin-dependent diabetic presents with developing loss of vision. The ophthalmologist discovers he has an early onset of quickly developing senile cataracts, which could not be considered a diabetic complication.
 
You should report a primary diagnosis code of 366.10, (Senile cataract, unspecified) without mention of complication, with a secondary diagnosis code of 250.02, (Type II non-insulin-dependent diabetes).
 
Had the cataracts been a complication of the diabetes in the second example, as with snowflake cataracts that result from over-hydration of the lens due to unstable blood sugar levels, the coding scenario would have been primary diagnosis code 366.44 (Cataract associated with other syndromes) and secondary diagnosis code 250.52.
 
"The ophthalmologist is not treating the diabetes, he is  evaluating the patient for loss of vision, and the definitive diagnosis is cataracts," says Raequell Duran, CPC, president of Practice Solutions in Santa Barbara, Calif.
 
However, some coders feel that the retinopathy or cataracts should be listed as the secondary diagnosis and the diabetes as the first. Apparently, most carriers are accepting both methods. "We code the disease process first," says Paula Thomas, CPC, of Southeastern Retina Associates in Chattanooga, Tenn. "We would code the diabetes first, and the retinopathy or edema or whatever secondary, but we would reference the PDR on the line items that we bill."

Carrier Policies Are Changing Rapidly

CMS' public recognition of the importance of diabetic eye exams as a preventive measure has made billing for the procedures a much smoother process. CMS acknowledges that the screenings that facilitate the early treatment of retinal changes caused by diabetes are more cost-effective.
 
Unfortunately, even Medicare doesn't pay for visual field tests when the diagnosis is 250.0x for diabetes, Searson says. So if the physician wants the patient to have a visual field test and the patient only has the diagnosis of 250.0x, Searson recommends that you "have the patients sign a waiver of liability, and explain that their insurance will not cover the test."
 
Many carriers have yet to update their policies to include the proper reimbursements for diabetic codes, both with and without ophthalmic manifestations, for diabetic screenings. Be sure to ask your local carrier for its diabetic screening coverage and its policies for paying for E/M services and eye codes submitted in conjunction with diabetes diagnoses.