Optometry Coding & Billing Alert

Hint: Make sure your specific diabetic Dx matches that of the patients primary care physician.

Many of us who are used to coding routine procedures may feel hesitant when faced with filing a claim for a patient with ophthalmic complications from diabetes. Armed with diagnosis basics and an understanding of manifestations, however, you can sail through diabetic patient coding -- heres how:

Master Decimal Places for Dx

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 optometrist 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 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 optometrists 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.

Its 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 dont show any retinal sign of the illness, he says.

Watch out: Payers may reject your claim if your diagnosis code doesnt match up with the diagnosis code the patients primary care physician (PCP) uses, states the Optometry article. For example, should the PCP use 250.41 (diabetes with renal manifestations) to describe a patients diagnosis and you put 250.00 on your claim, the inconsistency could trigger payer questions.

Make Underlying Disease Primary Dx

Some coders are unsure how to code for diabetic patient care when the patients primary physician hasnt yet diagnosed the disease.

You be the coder: The optometrist 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 hasnt 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 patients type of diabetes and the type of retinopathy -- because the edema doesnt 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.

Avoid Routine Exams for Diabetics

Another common sticking point when coding for diabetic care is whether or not 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 shouldnt ignore the HPI and forgo a medical exam when the patients history indicates a disease with a possibility of significant ocular manifestations, Gibson continues.

To protect yourself, 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.

Some patients will be glad you took the time to watch out for their best interests -- and others will demand you see them under their routine vision plans, probably because the copays are lower, they havent met their insurance deductibles, or they just think you are trying to bait and switch off their vision plans, Gibson says. This is a common no-win situation. Its your call on how to resolve this problem, but you have got to do a dilated comprehensive exam and should report to the patients diabetic -- doc whether you bill the exam to the health insurance company or the vision plan.

Note: For more information on billing for patients with both vision and routine insurance plans, see End Medical vs. Vision Insurance Confusion in Optometry Coding Alert, Vol. 6, No. 5.