Ophthalmology and Optometry Coding Alert

Sweet news for coders - you won't have to check insulin use to find the right diabetes code

Be ready for some big changes in how you assign diabetes diagnosis codes, starting with the release of the new ICD-9 codes Oct. 1.

Coding for patients who have diabetes with eye complications such as diabetic retinopathy can be difficult, says Brenda Parker, CPC, systems administrator for River Cities Ophthalmology in Ford Madison, Iowa. To classify the diabetes either type I or type II - and to arrive at the correct fifth digit - ophthalmology coders usually have to determine the patient's insulin use.

That won't be a problem anymore starting Oct. 1, when you may find it easier to assign diabetes ICD-9 codes (250.x-250.9x) because their descriptors no longer include the designations "insulin dependent" and "non-insulin dependent."

CMS recently announced new and revised ICD-9 codes for 2004-2005. When the changes take effect this fall, distinguishing between the diabetes codes' fifth digits will depend on whether or not the patient's pancreatic beta cells are functioning. The  National Center for Health Statistics and CMS oversee all ICD-9 changes.

Distinguish Between the Different Diabetes Types

Ophthalmologists now use insulin and non-insulin designations to determine whether a patient has type I or type II diabetes. Physicians also assign fifth digits to correspond with a patient's particular diabetes type. Even if another doctor - an endocrinologist, for example - has already diagnosed the patient, the ophthalmology coder is still responsible for assigning the correct ICD-9 code, Parker says.

But the problem with this system is that physicians often assign type I diabetes for any patient who's taking insulin, even though many type II patients use insulin, too, says Deborah Arneson, CPC, coding supervisor at Kernodle Clinic, a Burlington, N.C.-based group practice. That's why the insulin deletions are good changes that should alleviate a lot of confusion for physicians, she says.

Remember: Ophthalmologists still need to be as accurate as possible when they categorize the patient's type of diabetes, says Bruce Rappoport, MD, CPC, who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise.

"It is ultimately the physician who is responsible for determining which type of diabetes mellitus the patient has," Rappoport says.

Bottom line: Your ophthalmologist will probably not be able to tell you whether a patient's beta cells are functioning properly. Instead, what this change means is that you have two questions to ask a physician when choosing a diabetes code: 1. Controlled or uncontrolled? 2. Type I or type II?

Example: A 72-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. He notes type I diabetes in the chart and doesn't mention whether it's controlled or not.

You should report a primary diagnosis code of 362.02 (Proliferative diabetic retinopathy), and for the secondary diagnosis code you should report 250.51 (Diabetes with ophthalmic manifestations; type I [juvenile type], not stated as uncontrolled).

Be Ready - ICD-9 Changes Start Earlier This Year

You have no time to waste in getting your ophthalmology practice ready for the new diabetes descriptors. In February, CMS scrapped the 90-day grace period you once had to implement new ICD-9 codes, meaning your practice should begin using the revised fifth digits on Oct. 1. (For more information on grace periods, see "Say Goodbye to Your Coding Grace Periods" in the May 2004 Ophthalmology Coding Alert.)

Be careful: The physician must specifically state "uncontrolled" for you to choose a fifth digit of "2" or "3." The revised fifth-digit descriptors for 250.xx should appear in next year's ICD-9 manual as follows: