Ophthalmology and Optometry Coding Alert

If you're feeling hesitant about filing claims for patients with ophthalmic complications from diabetes, arm yourself with diagnosis basics and an understanding of manifestations to sail through diabetic patient coding.

One of the most common mistakes coders make when filling a claim on a diabetic patient is reporting 250.00 (Diabetes mellitus without mention of complication) for the diagnosis. "Code 250.00 alone generally is not sufficient to indicate the diagnosis of patients with diabetes," states the November 2004 issue of Optometry, the Journal of the American Optometric Association. Instead, you must specify the exact type of diabetes for which the ophthalmologist is providing care.

Why? Medicare and other third-party payers require a highly specific diagnosis to justify payment. That means that you must pay attention to the fourth and fifth places beyond the decimal point, which indicate any complications and the exact type of disease, states the AOA's publication.

Fourth place: The fourth place, or the first decimal place, indicates a complication. This includes codes 250.0x-250.9x. The complication indicator typically used in the ophthalmologist's office is 250.5x, which indicates ophthalmic manifestations.

Fifth place: The fifth place, or second decimal place, indicates the sub-classification of disease. In the case of diabetes, it is the "type," such as:

• 250.50 -- Diabetes with ophthalmic manifestations, type II or unspecified type,not stated as uncontrolled

• 250.51 -- ... type I [juvenile type], not stated as uncontrolled

• 250.52 -- ... type II or unspecified type, uncontrolled

• 250.53 -- ... type I [juvenile type], uncontrolled.

"It's important to remember that the diabetes codes are not based on whether or not the patient is insulin dependent or non-insulin dependent, but whether or not it is type I or type II diabetes," points out Carter Atkinson, CPC, with One Source Solutions, Inc. in Fayetteville, N.C. If you are unsure, the unspecified code 250.50 would be the correct choice -- if the patient has some manifestations of the illness, cautions David Gibson, OD, FAAO, an optometrist practicing in Lubbock, Texas. "Most of the diabetics I examine don't show any retinal sign of the illness," he says.

Watch out: Payers may reject your claim if your diagnosis code doesn't match up with the diagnosis code  the patient's primary care physician (PCP) uses, states the Optometry article. For example, should the PCP use 250.41 (Diabetes with renal manifestations) to describe a patient's diagnosis and you put 250.00 on your claim, the inconsistency could trigger payer questions. But it is more accurate to report ICD-9 code 250.5x as the primary diagnosis and reason for the encounter with the ophthalmologist.

Your claim may also show secondary diabetes diagnosis codes when known.

Some coders are unsure how to code for diabetic patient care when the patient's primary physician hasn't yet diagnosed the disease.

You be the coder: The ophthalmologist finds diabetic retinopathy in a patient identified as "pre-diabetic." Would you code 250.5x for diabetes with ophthalmic complications, plus 362.0x for the diabetic retinopathy or only code for retinopathy since the PCP hasn't formally diagnosed the patient as diabetic? "Correct coding requires you to report the 250.5x diagnosis as primary, then the retinopathy 362.0x diagnosis as secondary" whether the patient has officially been diagnosed with diabetes or not, explains Atkinson.

Why? Diabetic retinopathy is clearly a manifestation of the much larger systemic disease of diabetes, so you should identify diabetes as the primary diagnosis.

Rule: Any time you code a disease and its associated manifestations/complications, correct coding requires that you code the underlying disease first, and the corresponding manifestations/complications as secondary, Atkinson continues.

Example: Before you can code a manifestation such as diabetic macular edema (362.07), you must first code the patient's type of diabetes and the type of retinopathy -- because the edema oesn't exist without the retinopathy, Atkinson adds. When you order your diagnoses like this, you are communicating to the insurance company: "My patient has a form of diabetes (250.5x) with the ophthalmic complication/manifestation of retinopathy (362.0x) resulting in macular edema (362.07)."

V code: If the patient indicates that she routinely uses insulin, also code V58.67 (Long-term [current] use of insulin) in your final diagnosis, says Atkinson. However, the "V" codes should never be coded as a primary diagnosis, he adds.

Another common sticking point when coding for diabetic care is whether to use the routine exam codes.

Best bet: Treat diabetic patients' visits as non-routine medical exams. "In my opinion, there is no such thing as a routine exam in a diabetic patient," Gibson says. Since the diabetic patient has a disease affecting their blood vessels that poses a significant risk to their eyes, you should evaluate him as a high-risk patient whether they have complaints or not, he adds.

Rationale: While it is ideal to match up the patient complaint and the diagnosis, you shouldn't ignore the history of present illness (HPI) and forgo a medical exam when the patient's history indicates a disease with a possibility of significant ocular manifestations, Gibson continues.

To protect your code assignment, take steps to ensure that you have documentation regarding your discussion with the patient about the medical necessity of her exam. If a diabetic asks for a "routine" exam, pull out her chart, go over the notes, and refer to the diabetic history.